Genotype and dose-dependent response to an asbti in patients with bile salt export pump deficiency

ABSTRACT

Provided herein are methods for treating or ameliorating cholestatic liver disease in a subject in need thereof. The methods include administering an Apical Sodium-dependent Bile Acid Transport Inhibitor (ASBTI) to the subject. The methods include determining a genotype of the subject and predicting subject response to the ASBTI administration based upon the genotype. The methods further include determining, adjusting, or modulating a dose of the ASBTI administered to the subject based upon the genotype or upon measurements of clinically relevant disease parameters.

CROSS REFERENCE TO RELATED APPLICATIONS

This application claims the benefit under 35 U.S.C. § 119(e) of U.S.Provisional Applications Nos. 62/804,523, filed Feb. 12, 2019,62/863,904, filed Jun. 20, 2019, 62/908,431, filed Sep. 30, 2019, and62/932,015, filed Nov. 7, 2019, which are incorporated herein byreference in their entirety for all purposes.

FIELD OF THE INVENTION

The present invention relates generally to methods for treating orameliorating cholestatic liver disease. In particular, the inventionrelates to methods for modulating a dosage of an Apical Sodium-dependentBile Acid Transport Inhibitor (ASBTI) administered to a subject and tomethods for using subject genotype to predict response to ASBTIadministration at a particular dosage level.

BACKGROUND

Hypercholemia and cholestatic liver diseases are liver diseasesassociated with impaired bile secretion (i.e., cholestasis), associatedwith and often secondary to the intracellular accumulation of bileacids/salts in the hepatocyte. Hypercholemia is characterized byincreased serum concentration of bile acid or bile salt. Cholestasis canbe categorized clinicopathologically into two principal categories ofobstructive, often extrahepatic, cholestasis, and nonobstructive, orintrahepatic, cholestasis. Nonobstructive intrahepatic cholestasis canfurther be classified into two principal subgroups of primaryintrahepatic cholestasis that result from constitutively defective bilesecretion, and secondary intrahepatic cholestasis that result fromhepatocellular injury. Primary intrahepatic cholestasis includesdiseases such as benign recurrent intrahepatic cholestasis, which ispredominantly an adult form with similar clinical symptoms, andprogressive familial intrahepatic cholestasis (PFIC) types 1, 2, and 3,which are diseases that affect children.

Neonatal respiratory distress syndrome and lung pneumonia is oftenassociated with intrahepatic cholestasis of pregnancy. Active treatmentand prevention are limited. Currently, effective treatments forhypercholemia and cholestatic liver diseases include surgery, livertransplantation, and rarely administration of ursodiol. Effective andsafe medication for hypercholemia and cholestatic liver diseases isneeded.

SUMMARY OF THE INVENTION

Various non-limiting aspects and embodiments of the invention aredescribed below.

In one aspect, the present invention provides a method for treating orameliorating cholestatic liver disease in a subject in need thereof,wherein the subject has a bile salt export pump (BSEP) deficiency andthe method comprises administering to the subject an ApicalSodium-dependent Bile Acid Transport Inhibitor (ASBTI). In certainembodiments, the ASBTI is

or a pharmaceutically acceptable salt thereof. In certain embodiments,the ASBTI is maralixibat, or a pharmaceutically acceptable salt thereof.In some embodiments, the ASBTI is volixibat, or a pharmaceuticallyacceptable salt thereof. In various embodiments, the ASBTI isodevixibat, or a pharmaceutically acceptable salt thereof. In someembodiments, the ASBTI is elobixibat, or a pharmaceutically acceptablesalt thereof. In some embodiments, the ASBTI is GSK2330672, or apharmaceutically acceptable salt thereof.

In various embodiments, the cholestatic liver disease is progressivefamilial intrahepatic cholestasis type 2 (PFIC 2), benign recurrentintrahepatic cholestasis (BRIC) or intrahepatic cholestasis of pregnancy(ICP), or biliary atresia. In some embodiments, the subject has residualBSEP function. In various embodiments, the BSEP deficiency results inimpaired or reduced bile flow or cholestasis.

In some embodiments, an ABCB11 gene of the subject comprises anon-truncating mutation. In various embodiments, the ABCB11 genecomprises one or more of E297G, D482G, an alternative missense mutation,or a combination thereof. In certain embodiments, the ABCB11 genecomprises an E297G or a D482G mutation, or both. In various embodiments,the ABCB11 gene comprises a missense mutation and not an E297G or D482Gmutation.

In some embodiments, the method further comprises determining a genotypeof the subject. In some embodiments, determining the genotype comprisesidentifying and characterizing a mutation in the ABCB11 gene. In certainembodiments, the ABCB11 gene of the subject is characterized ascomprising only non-truncating mutations.

In various embodiments, the method comprises determining a ratio ofserum 7α-hydroxy-4-cholesten-2-one (7αC4) concentration to serum bileacid (sBA) concentration (7αC4:sBA) prior to administering the ASBTI ata first dose level (baseline ratio), and further determining 7αC4:sBAafter the ASBTI administration, where the ASBTI administration resultsin a 7αC4:sBA ratio about 2-fold or greater higher than the baseline7αC4:sBA ratio. In certain embodiments, if the 7αC4:sBA ratio begins todecrease or decreases to less than 2-fold or greater higher thanbaseline, a second dose level of the ASBTI is administered to thesubject. The second dose level is higher than the first dose level.

In various embodiments, the method comprises determining a ratio ofserum 7αC4 concentration to sBA concentration (7αC4:sBA) prior toadministering the ASBTI at a first dose level (baseline ratio), andfurther determining 7αC4:sBA after the ASBTI administration, wherein ifthe ASBTI administration fails to result in a 7αC4:sBA ratio about2-fold or greater higher than the baseline 7αC4:sBA ratio, the subjectis administered a second dose level of the ASBTI, wherein the seconddose level is higher than the first dose level.

In various embodiments, the method further comprises modulating a doseof the ASBTI, the modulating comprising determining a ratio of serum7αC4 concentration to sBA concentration (7αC4:sBA) prior toadministering the ASBTI at a first dose level (baseline ratio), andfurther determining 7αC4:sBA after the ASBTI administration, wherein ifthe ASBTI administration fails to result in a 7αC4:sBA ratio about2-fold or greater higher than the baseline 7αC4:sBA ratio the ASBTI isthen administered at a second dose level that does result in a 7αC4:sBAratio that is about a 2-fold or greater higher than the baseline ratio.In various embodiments, the second dose is at least about twice and lessthan about five times the first dose.

In various embodiments, the method further comprises modulating a doseof the ASBTI, the modulating comprising determining a ratio of serum7αC4 concentration to sBA concentration (7αC4:sBA) prior toadministering the ASBTI at a first dose level (baseline ratio), andfurther determining 7αC4:sBA after the ASBTI administration, wherein ifa treating physician believes the ratio could be elevated beyond thecurrent level with a higher dose level of the ASBTI, then the subject isadministered the ASBTI at a second dose level that results in a 7αC4:sBAratio that is higher than the baseline ratio.

In certain embodiments, the subject is a pediatric subject under 18years of age. In some embodiments, administration of the ASBTI resultsin improved growth of the subject relative to baseline growth. Invarious embodiments, the improved growth of the subject is measured asan increase in height z-score.

In some embodiments, the ASBTI is administered at a daily dose of fromabout 140 μg/kg to about 1400 μg/kg. In some embodiments, the ASBTI isadministered once daily. In various embodiments, the ASBTI isadministered twice daily. In various embodiments, the ASBTI isadministered at a daily dose of from about 5 mg/day to about 100 mg/day.In some embodiments, the ASBTI is administered regularly for a period ofat least one year. In certain embodiments, the ASBTI is administeredregularly for a period of at least 4 years.

In various embodiments, the administration of the ASBTI results in areduction in a symptom or a change in a disease-relevant laboratorymeasure of the cholestatic liver disease that is maintained for at leastone year. In various embodiments, the reduction in a symptom or a changein a disease-relevant laboratory measure comprises a reduction in sBAconcentration, an increase in serum 7αC4 concentration, an increase in aratio of serum 7αC4 concentration to sBA concentration (7αC4:sBA), areduction in pruritis, an increase in a quality of life inventory score,an increase in a quality of life inventory score related to fatigue, ora combination thereof. In some embodiments, the reduction in the symptomor a change in a disease-relevant laboratory measure is determinedrelative to a baseline level. In various embodiments, the subject is apediatric subject under 18 years of age, and the reduction in a symptomor a change in a disease-relevant laboratory measure comprises anincrease in growth.

In some embodiments, the administration of the ASBTI results in anincrease in serum 7αC4 concentration. In various embodiments, the serum7αC4 concentration is increased from about 1.5-fold to about 40-foldrelative to baseline. In some embodiments, the administration of theASBTI results in an increase in a ratio of serum 7αC4 concentration tosBA concentration (7αC4:sBA). In certain embodiments, the 7αC4:sBA isincreased by from about 2-fold to about 5,000-fold relative to baseline.

In various embodiments, the administration of the ASBTI results in anincrease in fecal bile acids (fBA) of at least 100% relative tobaseline. In some embodiments, the administration of the ASBTI resultsin a decrease in sBA concentration of at least about 70% relative tobaseline.

In various embodiments, the administration of the ASBTI results in areduction in severity of pruritus. In some embodiments, the reduction inseverity of pruritis is measured as a reduction of at least 1.0 in anobserver-reported itch reported outcome (ITCHRO(OBS)) score. In someembodiments, the administration of the ASBTI results in an ITCHRO(OBS)score of ≤1. In various embodiments, the administration of the ASBTIresults in an increase in a quality of life inventory score.

In some embodiments, the quality of life inventory score is ahealth-related quality of life (HRQoL) score. In some embodiments, thequality of life inventory score is a Pediatric Quality of Life Inventory(PedsQL) score, and the PedsQL score is increased by at least 10%relative to baseline.

In various embodiments, the serum bilirubin concentration is atpre-administration baseline level at about 4 months after firstadministration of the ASBTI. In various embodiments, serum alanineaminotransferase (ALT) concentration is at pre-administration baselinelevel at about 4 months after first administration of the ASBTI. In someembodiments, serum aspartate aminotransferase (AST) concentration, andserum bilirubin concentration are within a normal range at about 4months after first administration of the ASBTI. In some embodiments, theadministration of the ASBTI results in serum ALT concentrationdecreasing by at least about 10% relative to baseline.

In various embodiments, the subject has biliary atresia or intrahepaticcholestasis of pregnancy.

In one aspect, the present invention provides a method for predictingsubject response to treatment of a cholestatic liver disease. Thetreatment comprises administering to the subject in need of suchtreatment an ASBTI. The method comprises determining a genotype of thesubject and predicting subject response to the treatment based upon thegenotype.

In various embodiments, the ASBTI is

or a pharmaceutically acceptable salt thereof. In some embodiments, theASBTI is maralixibat, or an alternative pharmaceutically acceptable saltthereof. In certain embodiments, the ASBTI is volixibat, or apharmaceutically acceptable salt thereof. In various embodiments, theASBTI is odevixibat, or a pharmaceutically acceptable salt thereof. Insome embodiments, the ASBTI is elobixibat, or a pharmaceuticallyacceptable salt thereof. In various embodiments, the ASBTI isGSK2330672, or a pharmaceutically acceptable salt thereof.

In various embodiments, the method includes determining the genotypecomprises determining a sequence of an ABCB11 gene. In some embodiments,the method includes identifying and characterizing a mutation of theABCB11 gene. In various embodiments, the method further comprisespredicting that the subject will not be responsive to administration ofthe ASBTI if the ABCB11 gene comprises a truncating mutation. In someembodiments, the method comprises predicting that the subject will notbe responsive to administration of the ASBTI if the ABCB11 genecomprises a mutation resulting in total loss of BSEP activity. In someembodiments, the method includes predicting that the subject will beresponsive to administration of the ASBTI if the ABCB11 gene comprisesmutations that result in residual BSEP activity and the ABCB11 genecomprises no mutations that result in absence of BSEP activity. In someembodiments, the ABCB11 gene comprises one or more of an E297G, D482G,an alternative missense mutation, or some combination thereof. Invarious embodiments, the method includes administering an ASBTI to thesubject if the subject is predicted to be responsive to theadministration of the ASBTI.

In some embodiments, the subject has biliary atresia or intrahepaticcholestasis of pregnancy.

In one aspect, the present invention provides a method for treating orameliorating cholestatic liver disease in a subject in need thereof. Thesubject has a BSEP deficiency. The method includes determining agenotype of the subject, using the genotype of the subject to predictwhether the subject will be or will not be responsive to treatment withan ASBTI, and administering an ASBTI to the subject if the subject ispredicted to be responsive to administration of the ASBTI.

In various embodiments, determining the genotype comprises determining asequence of an ABCB11 gene. In some embodiments, the method includesidentifying and characterizing a mutation of the ABCB11 gene. In variousembodiments, the method comprises predicting that the subject will notbe responsive to administration of the ASBTI if the ABCB11 genecomprises a truncating mutation. In some embodiments, the methodincludes predicting that the subject will not be responsive toadministration of the ASBTI if the ABCB11 gene comprises a mutationresulting in total loss of BSEP activity. In some embodiments, themethod includes predicting that the subject will be responsive toadministration of the ASBTI if the ABCB11 gene comprises mutations thatresult in residual BSEP activity and the ABCB11 gene comprises nomutations that result in absence of BSEP activity. In variousembodiments, the ABCB11 gene comprises one or more of an E297G, D482G,an alternative missense mutation, or some combination thereof.

In various embodiments, the method includes determining a ratio of serum7αC4 concentration to serum bile acid (sBA) concentration (7αC4:sBA)prior to administering the ASBTI at a first dose (baseline ratio), andfurther determining the 7αC4:sBA after the ASBTI administration. In someembodiments, the method includes administering a second dose of theASBTI, where the second dose is greater than the first dose, if afterthe administration of the first dose of the ASBTI the 7αC4:sBA is notmaintained about >2-fold higher than the baseline ratio.

In certain embodiments, the method comprises administering a second doseof the ASBTI, where the second dose is greater than the first dose, ifthe 7αC4:sBA initially increases by at least >2-fold higher than thebaseline ratio and then begins to decrease back to the baseline ratio.In some embodiments, the second dose is at least about twice and lessthan about five times the second dose.

In some embodiments, the subject is a pediatric subject under 18 yearsof age. In various embodiments, the administration of the ASBTI resultsin improved growth of the subject. In various embodiments, improvedgrowth of the subject is measured as an increase in height z-score.

In some embodiments, the ASBTI is administered at a daily dose of fromabout 140 μg/kg to about 1400 μg/kg. In various embodiments, the ASBTIis administered once daily. In some embodiments, the ASBTI isadministered twice daily. In certain embodiments, the ASBTI isadministered at a dose of from about 5 mg/day to about 100 mg/day. Invarious embodiments, the ASBTI is administered regularly for a period ofat least one year. In some embodiments, the ASBTI is administeredregularly for a period of at least 4 years.

In various embodiments, administration of the ASBTI results in areduction in a symptom or a change in a disease-relevant laboratorymeasure of the cholestatic liver disease that is maintained for at leastone year. In various embodiments, the reduction in a symptom or a changein a disease-relevant laboratory measure comprises a reduction in sBAconcentration, an increase in serum 7αC4 concentration, an increase in aratio of serum 7αC4 concentration to sBA concentration (7αC4:sBA), areduction in pruritis, an increase in a quality of life inventory score,an increase in a quality of life inventory score related to fatigue, ora combination thereof. In some embodiments, the reduction in the symptomor a change in a disease-relevant laboratory measure is determinedrelative to a baseline level. In various embodiments, the subject is apediatric subject under 18 years of age and the reduction in a symptomor a change in a disease-relevant laboratory measure comprises anincrease in growth.

In certain embodiments, the administration of the ASBTI results in anincrease in serum 7αC4 concentration. In various embodiments, the serum7αC4 concentration is increased from about 1.5-fold to about 40-foldrelative to baseline. In some embodiments, the serum 7αC4 concentrationis increased by at least 100% relative to baseline.

In some embodiments, the administration of the ASBTI results in anincrease in a ratio of serum 7αC4 concentration to sBA concentration(7(C4:sBA). In some embodiments, 7αC4:sBA is increased by from about2-fold to about 5,000-fold relative to baseline.

In various embodiments, the administration of the ASBTI results in anincrease in fBA of at least 100% relative to baseline. In someembodiments, the administration of the ASBTI results in a decrease insBA concentration of at least about 70% relative to baseline.

In some embodiments, administration of the ASBTI results in a reductionin severity of pruritus. In various embodiments, the reduction inseverity of pruritis is measured as a reduction of at least 1.0 in anobserver-reported itch reported outcome (ITCHRO(OBS)) score relative tobaseline. In some embodiments, the administration of the ASBTI resultsin an ITCHRO(OBS) score of ≤1.

In various embodiments, the administration of the ASBTI results in anincrease in a quality of life inventory score. In some embodiments, thequality of life inventory score is a health-related quality of life(HRQoL) score. In various embodiments, the quality of life inventoryscore is a Pediatric Quality of Life Inventory (PedsQL) score. Incertain embodiments, the PedsQL score is increased by at least 10%relative to baseline.

In some embodiments, serum bilirubin concentration is atpre-administration baseline level at about 4 months after firstadministration of the ASBTI. In various embodiments, serum ALTconcentration is at pre-administration baseline level at about 4 monthsafter first administration of the ASBTI. In various embodiments, serumALT concentration, serum AST concentration, and serum bilirubinconcentration being are within a normal range at about 4 months afterfirst administration of the ASBTI. In certain embodiments, theadministration of the ASBTI results in serum ALT concentrationdecreasing by at least about 10% relative to baseline.

In various embodiments, the subject has biliary atresia or intrahepaticcholestasis of pregnancy. In some embodiments, the subject has PFIC 2.

These and other aspects of the present invention will become apparent tothose skilled in the art after a reading of the following detaileddescription of the invention, including the appended claims.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 provides a schematic diagram summarizing physiological effects ofmaralixibat administration in a patient. CYP7A1, cholesterol7α-hydroxylase; FGF, fibroblast growth factor; FXR, famesoid X receptor.

FIG. 2 shows a schematic providing an overview of a dosing regimen usedin an INDIGO phase 2 open-label safety and efficacy clinical study(INDIGO clinical study) of maralixibat in children with PFIC. Theclinical study investigated long-term exposure to maralixibat.

FIGS. 3A-3F each provide quantitative summaries of response indicatorsmeasured for six responders that participated in the INDIGO clinicalstudy. The six responders were a girl aged 3 years (FIG. 3A), a boy aged10 years (FIG. 3B), a girl aged 6 years and sister of the boy aged 10years (FIG. 3C), a girl aged 4 years (FIG. 3D), a boy aged 3 years (FIG.3E), and a girl aged 1 year (FIG. 3F). Each of FIGS. 3A-3F providesthree scatter plots plotting sBA levels (concentrations), pruritusseverity score, and PEDIATRIC QUALITY OF LIFE INVENTORY (PEDSQL) scoresagainst study week, respectively. Pruritus severity score was measuredaccording to the clinical scratch score (CSS) and Itch Reported Outcome(ITCHRO) score. Each of FIGS. 3A-3F also provides a summary of changesobserved in ALT (alanine aminotransferase) and AST (aspartateaminotransferase) levels, bilirubin levels, and C4 levels for eachresponder.

FIG. 4 depicts a scatter plot showing height Z-score change frombaseline over time for responders and non-responders in the INDIGOclinical study. The decrease in average height Z-score at week 60 is dueto one patient not having a measurement for that time point.

FIGS. 5A and 5B provide scatter plots plotting serum bile acids (sBA)concentration over time for patients that participated in the INDIGOclinical study. FIG. 5A plots sBA concentrations over time for patientshaving non-truncating bile salt export pump (BSEP, which is encoded bythe ABCB11 gene) mutations. FIG. 5B plots sBA concentrations over timefor patients having truncating BSEP mutations. FIGS. 5A-5B demonstratethat sBA responses differed by BSEP mutation status. Black filledcircles indicate termination. White filled circles indicate start of BIDdosing (280 μg/kg BID). In FIGS. 5A and 5B lines corresponding tonon-responders are marked with a star.

FIG. 6 provides a scatter plot plotting observer-reported itch reportedoutcome (ITCHRO(OBS)) weekly average scores for patients participatingin the INDIGO clinical study and having non-truncating BSEP mutations.FIG. 6 demonstrates that ITCHRO(OBS) response was sustained over yearsand that >50% (10/19) patients demonstrated a ≥1.0 pt. reduction inITCHRO(OBS) score. Black filled circles indicate termination. Whitefilled circles indicate commencement of BID dosing (280 μg/kg BID). TheITCHRO(OBS) scale range is 0 to 4. In FIG. 6 lines corresponding tonon-responders are marked with a star.

FIG. 7 provides a scatter plot plotting mean serum7α-hydroxy-4-choesten-3-one (7αC4 or C4) concentration over time forpatients participating in the INDIGO clinical study and havingnon-truncating BSEP mutations. FIG. 7 demonstrates that non-truncatingBSEP mutation responders showed significant increases in 7αC4concentration. Black filled circles indicate termination. White filledcircles indicate commencement of BID dosing (280 μg/kg BID). TheITCHRO(OBS) scale range is 0 to 4. In FIG. 7 lines corresponding tonon-responders are marked with a star.

FIG. 8 provides a scatter plot showing the ratio of 7αC4 concentrationto sBA concentration (7αC4:sBA) over time for patients participating inthe INDIGO clinical study and having non-truncating BSEP mutations. FIG.8 demonstrates that non-truncating BSEP mutation responders hadsignificantly different 7αC4:sBA ratios than non-responders. Twonon-truncating BSEP mutation responders showed an increase in 7αC4:sBAratio following dose elevation. Black filled circles indicatetermination. White filled circles indicate commencement of BID dosing(280 μg/kg BID). The ITCHRO(OBS) scale range is 0 to 4. In FIG. 8 linescorresponding to non-responders are marked with a star.

FIG. 9 provides a bar graph showing mean change from baseline to day 6and 7 in fecal bile acid (fBA) excretion across indicated doses ofmaralixibat, volixibat, and placebo for a phase 1, blinded, placebocontrolled, dose ranging clinical study (NCT02475317). BID, twice daily;QD, once daily; SE, standard error.

FIG. 10 provides a bar graph showing mean change from baseline to day 7in serum 7αC4 concentration across indicated doses of maralixibat,volixibat, and placebo. BID, twice daily; fBA, fecal bile acids; QD,once daily; SE, standard error.

FIG. 11 provides a bar graph showing mean ITCHRO weekly sum scores in anoverall population of participants in a 14-week, single-arm, open-label,phase 2a, proof-of-concept study of maralixibat (CAMEO clinical study)having any pruritus at baseline, and participants with ITCHRO dailyscores ≥4 at baseline.

FIG. 12 shows bar plots of sBA concentration (left panel) and 7αC4concentration (right panel) in an overall population participating inthe CAMEO clinical study and in participants with ITCHRO daily scores ≥4at baseline.

FIG. 13 shows bar plots of serum autotaxin concentration (left panel)and serum low-density lipoprotein cholesterol (LDL-C) concentration(right panel) in the overall population participating in the CAMEOclinical study and in participants with ITCHRO daily scores ≥4 atbaseline.

FIG. 14 shows a bar plot of percentage change from baseline to week 14or early termination on efficacy measures including ITCHRO score (1-10daily score), sBA concentration, and serum autotaxin concentration insix participants in the CAMEO clinical study with ITCHRO daily scores ≥4at baseline.

FIG. 15 provides a diagram summarizing the clinical study design for adouble blind, randomized, placebo controlled drug withdrawal study witha long-term open label treatment period of maralixibat 400 μg/kg QD(ICONIC clinical study).

FIG. 16 provides a diagram summarizing the disposition of participantsin the ICONIC clinical study.

FIGS. 17A and 17B demonstrate significant improvements in sBA levelsversus baseline and placebo in participants in the ICONIC clinicalstudy. FIG. 17A shows a graph plotting mean change in sBA concentrationfrom baseline in all participants through week 48.

FIG. 17B shows a bar graph showing mean change in sBA from week 8-22 insBA responders during a randomized withdrawal.

FIG. 18 shows a plot of mean sBA concentrations for participants in theICONIC clinical study during the core study (first 48 weeks) and duringthe extension (period after 48 weeks). MRX=maralixibat; PLA=placebo.

FIG. 19 provides a bar graph showing mean change from baseline (BL) insBA levels observed in the ICONIC clinical study.

FIGS. 20A and 20B demonstrate improvements in ITCHRO(Obs) scoresmaintained during randomized withdrawal with maralixibat in participantsin the ICONIC clinical study. FIG. 20A shows mean change from baselinein ITCHRO(OBS) score for participants over time. FIG. 20B shows a plotof ITCHRO(OBS) score for participants during a placebo-controlledwithdrawal period.

FIGS. 21A and 21B demonstrates improvements from baseline in clinicianscratch scale (CSS) scores throughout the ICONIC clinical study. FIG.21A shows proportions of total patients having indicated CSS scores atbaseline, week 18, and week 48.

FIG. 21B shows proportions of total patients administered maralixibat orplacebo having indicated CSS scores during a placebo-controlledwithdrawal period at week 22.

FIG. 22 shows change from baseline (BL) in CSS score for participants inthe ICONIC clinical study at week 48 and at week 191.

FIGS. 23A-23D provide plots of weekly average ITCHRO(OBS) score overtime for participants in the ICONIC clinical study during the core studyand during the extension.

FIG. 23A provides a scatter plot showing average ITCHRO(OBS) score overtime. FIG. 23B shows that reductions in pruritus were maintained in thelong-term extension. Each line represents ITCHRO(OBS) scores for anindividual patient. FIGS. 23C and 23D show that reductions in prurituswere maintained with maralixibat but not with switch to placebowithdrawal period (indicated by boxed area of the plot). Each linerepresents ITCHRO(OBS) scores for an individual patient.MRX=maralixibat; PLA=placebo. N=number of participants measured at anindicated timepoint.

FIG. 24 shows change from baseline (BL) in ITCHRO(OBS) score at 48 weeksand at 193 weeks for participants in the ICONIC clinical study.

FIG. 25 provides a bar graph showing proportion of study days withITCHRO(OBS) score ≤1 across all participants (%) in the ICONIC clinicalduring administration of placebo and during administration ofmaralixibat.

FIG. 26 shows a plot of HRQoL scores over time for patientsparticipating in the ICONIC clinical study. HRQoL scores were measuredas PEDSQL scores.

FIG. 27 provides a bar graph showing change from baseline (BL) in PEDSQLfatigue scale score (scale of 0-100) at week 48 and at week 191 forparticipants in the ICONIC clinical study. n=number of participantsrepresented at an indicated time point.

FIG. 28 shows a plot of Clinician Xanthoma Scale scores over time forpatients participating in the ICONIC clinical study.

FIG. 29 provides a bar graph showing change from baseline (BL) inclinician xanthoma scale score for participants in the ICONIC clinicalstudy at week 48 and at week 191.

FIG. 30 provides a scatter plot showing serum concentrations ofindicators of liver function over time for participants in the ICONICclinical study. GGT, gamma-glutamyl transpeptidase.

FIG. 31 shows a plot of percent change from baseline in sBA againstITCHRO(OBS) weekly morning average score change from baseline forparticipants in the ICONIC clinical study at week 48.

FIG. 32A-32H show lattice plots for each participant (identified bysubject number above each plot) in the ICONIC clinical study throughweek 48. FIGS. 32A-32H show lattice plots of sBA concentration (blue;left axis; μmol/L) and ITCHRO(OBS) weekly average score (red; rightaxis) over time (lower axis) for each participant in the ICONIC clinicalstudy. FIGS. 32A and 32D show lattice plots for patients in anMRX-MRX-MRX study group, which includes only those patients administeredmaralixibat before, during, and after a placebo-controlleddrug-withdrawal period of the ICONIC clinical study. FIGS. 32E and 32Hshow lattice plots for patients in an MRX-Placebo-MRX study group, whichincludes only those patients administered maralixibat before, placeboduring, and maralixibat again after the placebo-controlleddrug-withdrawal period. Patient 090004 did not have post-baselineassessments done, so the baseline datapoint is not visible in a plot.

FIG. 33 shows a scatter plot of mean change from baseline in heightZ-score over time for all participants in the ICONIC clinical study. Thenumber of patients (N) measured at each data point is indicated beneaththe x-axis. BL=baseline.

FIG. 34 shows a scatter plot of mean change from baseline in heightZ-score over time for participants in the ICONIC clinical study whoconsented to a long-term extension of the ICONIC clinical study and madeit to approximately four years as participants in the study (n=15). Thenumber of patients (N) measured at each data point is indicated beneaththe x-axis. BL=baseline.

FIG. 35 shows a scatter plot of mean change from baseline in weightZ-score over time for all participants in the ICONIC clinical study(n=31). The number of patients (N) measured at each data point isindicated beneath the x-axis. BL=baseline.

FIG. 36 shows a scatter plot of mean change from baseline in heightZ-score over time for participants in the ICONIC clinical study whoconsented to a long-term extension of the ICONIC clinical study and madeit to approximately four years as participants in the study (n=15). Thenumber of patients (N) measured at each data point is indicated beneaththe x-axis. BL=baseline.

DETAILED DESCRIPTION

Detailed embodiments of the present invention are disclosed herein;however, it is to be understood that the disclosed embodiments aremerely illustrative of the invention that may be embodied in variousforms. In addition, each of the examples given in connection with thevarious embodiments of the invention is intended to be illustrative, andnot restrictive. Therefore, specific structural and functional detailsdisclosed herein are not to be interpreted as limiting, but merely as arepresentative basis for teaching one skilled in the art to variouslyemploy the present invention.

Bile acids/salts play a critical role in activating digestive enzymesand solubilizing fats and fat-soluble vitamins and are involved inliver, biliary, and intestinal disease. Bile acids are synthesized inthe liver by a multistep, multiorganelle pathway. Hydroxyl groups areadded to specific sites on the steroid structure, the double bond of thecholesterol B ring is reduced, and the hydrocarbon chain is shortened bythree carbon atoms resulting in a carboxyl group at the end of thechain. The most common bile acids are cholic acid and chenodeoxycholicacid (the “primary bile acids”). Before exiting the hepatocytes andforming bile, the bile acids are conjugated to either glycine (toproduce glycocholic acid or glycochenodeoxycholic acid) or taurine (toproduce taurocholic acid or taurochenodeoxycholic acid). The conjugatedbile acids are called bile salts and their amphipathic nature makes themmore efficient detergents than bile acids. Bile salts, not bile acids,are found in bile.

Bile salts are excreted by the hepatocytes into the canaliculi to formbile. The canaliculi drain into the right and left hepatic ducts and thebile flows to the gallbladder. Bile is released from the gallbladder andtravels to the duodenum, where it contributes to the metabolism anddegradation of fat. The bile salts are reabsorbed in the terminal ileumand transported back to the liver via the portal vein. Bile salts oftenundergo multiple enterohepatic circulations before being excreted viafeces. A small percentage of bile salts may be reabsorbed in theproximal intestine by either passive or carrier-mediated transportprocesses. Most bile salts are reclaimed in the distal ileum by asodium-dependent apically located bile acid transporter referred to asapical sodium-dependent bile acid transporter (ASBT). At the basolateralsurface of the enterocyte, a truncated version of ASBT is involved invectoral transfer of bile acids/salts into the portal circulation.Completion of the enterohepatic circulation occurs at the basolateralsurface of the hepatocyte by a transport process that is primarilymediated by a sodium-dependent bile acid transporter. Intestinal bileacid transport plays a key role in the enterohepatic circulation of bilesalts. Molecular analysis of this process has recently led to importantadvances in understanding of the biology, physiology and pathophysiologyof intestinal bile acid transport.

Within the intestinal lumen, bile acid concentrations vary, with thebulk of the reuptake occurring in the distal intestine. Described hereinare certain compositions and methods that control bile acidconcentrations in the intestinal lumen, thereby controlling thehepatocellular damage caused by bile acid accumulation in the liver.

Classes of Cholestasis and Cholestatic Liver Disease

As used herein, “cholestasis” means the disease or symptoms comprisingimpairment of bile formation and/or bile flow. As used herein,“cholestatic liver disease” means a liver disease associated withcholestasis. Cholestatic liver diseases are often associated withjaundice, fatigue, and pruritis. Biomarkers of cholestatic liver diseaseinclude elevated serum bile acid concentrations, elevated serum alkalinephosphatase (AP), elevated gamma-glutamyltranspeptidease, elevatedconjugated hyperbilirubinemia, and elevated serum cholesterol.

Cholestatic liver disease can be sorted clinicopathologically betweentwo principal categories of obstructive, often extrahepatic,cholestasis, and nonobstructive, or intrahepatic, cholestasis. In theformer, cholestasis results when bile flow is mechanically blocked, asby gallstones or tumor, or as in extrahepatic biliary atresia.

The latter group who has nonobstructive intrahepatic cholestasis in turnfall into two principal subgroups. In the first subgroup, cholestasisresults when processes of bile secretion and modification, or ofsynthesis of constituents of bile, are caught up secondarily inhepatocellular injury so severe that nonspecific impairment of manyfunctions can be expected, including those subserving bile formation. Inthe second subgroup, no presumed cause of hepatocellular injury can beidentified. Cholestasis in such patients appears to result when one ofthe steps in bile secretion or modification, or of synthesis ofconstituents of bile, is constitutively damaged. Such cholestasis isconsidered primary.

Accordingly, provided herein are methods and compositions forstimulating epithelial proliferation and/or regeneration of intestinallining and/or enhancement of the adaptive processes in the intestine inindividuals with hypercholemia and/or a cholestatic liver disease. Insome of such embodiments, the methods comprise increasing bile acidconcentrations and/or GLP-2 concentrations in the intestinal lumen.

Increased levels of bile acids, and elevated levels of AP (alkalinephosphatase), LAP (leukocyte alkaline phosphatase), gamma GT(gamma-glutamyl transpeptidase), and 5′-nucleotidase are biochemicalhallmarks of cholestasis and cholestatic liver disease. Accordingly,provided herein are methods and compositions for stimulating epithelialproliferation and/or regeneration of intestinal lining and/orenhancement of the adaptive processes in the intestine in individualswith hypercholemia, and elevated levels of AP (alkaline phosphatase),LAP (leukocyte alkaline phosphatase), gamma GT (gamma-glutamyltranspeptidase or GGT), and/or 5′-nucleotidase. In some of suchembodiments, the methods comprise increasing bile acid concentrations inthe intestinal lumen. Further provided herein, are methods andcompositions for reducing hypercholemia, and elevated levels of AP(alkaline phosphatase), LAP (leukocyte alkaline phosphatase), gamma GT(gamma-glutamyl transpeptidase), and 5′-nucleotidase comprising reducingoverall serum bile acid load by excreting bile acid in the feces.

Pruritus is often associated with hypercholemia and cholestatic liverdiseases. It has been suggested that pruritus results from bile saltsacting on peripheral pain afferent nerves. The degree of pruritus varieswith the individual (i.e., some individuals are more sensitive toelevated levels of bile acids/salts).

Administration of agents that reduce serum bile acid concentrations hasbeen shown to reduce pruritus in certain individuals. Accordingly,provided herein are methods and compositions for stimulating epithelialproliferation and/or regeneration of intestinal lining and/orenhancement of the adaptive processes in the intestine in individualswith pruritus. In some of such embodiments, the methods compriseincreasing bile acid concentrations in the intestinal lumen. Furtherprovided herein, are methods and compositions for treating prurituscomprising reducing overall serum bile acid load by excreting bile acidin the feces.

Another symptom of hypercholemia and cholestatic liver disease is theincrease in serum concentration of conjugated bilirubin. Elevated serumconcentrations of conjugated bilirubin result in jaundice and darkurine. The magnitude of elevation is not diagnostically important as norelationship has been established between serum levels of conjugatedbilirubin and the severity of hypercholemia and cholestatic liverdisease. Conjugated bilirubin concentration rarely exceeds 30 mg/dL.Accordingly, provided herein are methods and compositions forstimulating epithelial proliferation and/or regeneration of intestinallining and/or enhancement of the adaptive processes in the intestine inindividuals with elevated serum concentrations of conjugated bilirubin.In some of such embodiments, the methods comprise increasing bile acidconcentrations in the intestinal lumen. Further provided herein, aremethods and compositions for treating elevated serum concentrations ofconjugated bilirubin comprising reducing overall serum bile acid load byexcreting bile acid in the feces.

Increased serum concentration of nonconjugated bilirubin is alsoconsidered diagnostic of hypercholemia and cholestatic liver disease.Portions of serum bilirubin and covalently bound to albumin (deltabilirubin or biliprotein). This fraction may account for a largeproportion of total bilirubin in patients with cholestatic jaundice. Thepresence of large quantities of delta bilirubin indicates long-standingcholestasis. Delta bilirubin in cord blood or the blood of a newborn isindicative of cholestasis/cholestatic liver disease that antedatesbirth. Accordingly, provided herein are methods and compositions forstimulating epithelial proliferation and/or regeneration of intestinallining and/or enhancement of the adaptive processes in the intestine inindividuals with elevated serum concentrations of nonconjugatedbilirubin or delta bilirubin. In some of such embodiments, the methodscomprise increasing bile acid concentrations in the intestinal lumen.Further provided herein, are methods and compositions for treatingelevated serum concentrations of nonconjugated bilirubin and deltabilirubin comprising reducing overall serum bile acid load by excretingbile acid in the feces.

Cholestasis and cholestatic liver disease results in hypercholemia.During metabolic cholestasis, the hepatocytes retains bile salts. Bilesalts are regurgitated from the hepatocyte into the serum, which resultsin an increase in the concentration of bile salts in the peripheralcirculation. Furthermore, the uptake of bile salts entering the liver inportal vein blood is inefficient, which results in spillage of bilesalts into the peripheral circulation. Accordingly, provided herein aremethods and compositions for stimulating epithelial proliferation and/orregeneration of intestinal lining and/or enhancement of the adaptiveprocesses in the intestine in individuals with hypercholemia. In some ofsuch embodiments, the methods comprise increasing bile acidconcentrations in the intestinal lumen. Further provided herein, aremethods and compositions for treating hypercholemia comprising reducingoverall serum bile acid load by excreting bile acid in the feces.

Hyperlipidemia is characteristic of some but not all cholestaticdiseases. Serum cholesterol is elevated in cholestasis due to thedecrease in circulating bile salts which contribute to the metabolismand degradation of cholesterol. Cholesterol retention is associated withan increase in membrane cholesterol content and a reduction in membranefluidity and membrane function. Furthermore, as bile salts are themetabolic products of cholesterol, the reduction in cholesterolmetabolism results in a decrease in bile acid/salt synthesis. Serumcholesterol observed in children with cholestasis ranges between about1,000 mg/dL and about 4,000 mg/dL. Accordingly, provided herein aremethods and compositions for stimulating epithelial proliferation and/orregeneration of intestinal lining and/or enhancement of the adaptiveprocesses in the intestine in individuals with hyperlipidemia. In someof such embodiments, the methods comprise increasing bile acidconcentrations in the intestinal lumen. Further provided herein, aremethods and compositions for treating hyperlipidemia comprising reducingoverall serum bile acid load by excreting bile acid in the feces.

In individuals with hypercholemia and cholestatic liver diseases,xanthomas develop from the deposition of excess circulating cholesterolinto the dermis. The development of xanthomas is more characteristic ofobstructive cholestasis than of hepatocellular cholestasis. Planarxanthomas first occur around the eyes and then in the creases of thepalms and soles, followed by the neck. Tuberous xanthomas are associatedwith chronic and long-term cholestasis. Accordingly, provided herein aremethods and compositions for stimulating epithelial proliferation and/orregeneration of intestinal lining and/or enhancement of the adaptiveprocesses in the intestine in individuals with xanthomas. In some ofsuch embodiments, the methods comprise increasing bile acidconcentrations in the intestinal lumen. Further provided herein, aremethods and compositions for treating xanthomas comprising reducingoverall serum bile acid load by excreting bile acid in the feces.

In children with chronic cholestasis, one of the major consequences ofhypercholemia and cholestatic liver disease is failure to thrive.Failure to thrive is a consequence of reduced delivery of bile salts tothe intestine, which contributes to inefficient digestion and absorptionof fats, and reduced uptake of vitamins (vitamins E, D, K, and A are allmalabsorbed in cholestasis). Furthermore, the delivery of fat into thecolon can result in colonic secretion and diarrhea. Treatment of failureto thrive involves dietary substitution and supplementation withlong-chain triglycerides, medium-chain triglycerides, and vitamins.Ursodeoxycholic acid, which is used to treat some cholestaticconditions, does not form mixed micelles and has no effect on fatabsorption. Accordingly, provided herein are methods and compositionsfor stimulating epithelial proliferation and/or regeneration ofintestinal lining and/or enhancement of the adaptive processes in theintestine in individuals (e.g., children) with failure to thrive. Insome of such embodiments, the methods comprise increasing bile acidconcentrations in the intestinal lumen. Further provided herein, aremethods and compositions for treating failure to thrive comprisingreducing overall serum bile acid load by excreting bile acid in thefeces.

Primary Biliary Cirrhosis (PBC)

Primary biliary cirrhosis is an autoimmune disease of the livercharacterized by the destruction of the bile canaliculi. Damage to thebile cancliculi results in the build-up of bile in the liver (i.e.,cholestasis). The retention of bile in the liver damages liver tissueand may lead to scarring, fibrosis, and cirrhosis. PBC usually presentsin adulthood (e.g., ages 40 and over). Individuals with PBC oftenpresent with fatigue, pruritus, and/or jaundice. PBC is diagnosed if theindividual has elevated AP concentrations for at least 6 months,elevated gammaGT levels, antimitochondrial antibodies (AMA) in the serum(>1:40), and florid bile duct lesions. Serum ALT and serum AST andconjugated bilirubin may also be elevated, but these are not considereddiagnostic. Cholestasis associated with PBC has been treated orameliorated by administration of ursodeoxycholic acid (UDCA orUrsodiol). Corticosteroids (e.g., prednisone and budesonide) andimmunosuppressive agents (e.g., azathioprine, cyclosporin A,methotrexate, chlorambucil and mycophenolate) have been used to treatcholestasis associated with PBC. Sulindac, bezafibrate, tamoxifen, andlamivudine have also been shown to treat or ameliorate cholestasisassociated with PBC.

Progressive Familial Intrahepatic Cholestasis (PFIC)

PFIC is a rare genetic disorder that causes progressive liver diseasetypically leading to liver failure. In people with PFIC, liver cells areless able to secrete bile. The resulting buildup of bile causes liverdisease in affected individuals. Signs and symptoms of PFIC typicallybegin in infancy. Patients experience severe itching, jaundice, failureto grow at the expected rate (failure to thrive), and an increasinginability of the liver to function (liver failure). The disease isestimated to affect one in every 50,000 to 100,000 births in the UnitedStates and Europe. Six types of PFIC have been genetically identified,all of which are similarly characterized by impaired bile flow andprogressive liver disease.

PFIC 1

PFIC 1 (also known as, Byler disease or FIC1 deficiency) is associatedwith mutations in the ATP8B1 gene (also designated as FIC1). This gene,which encodes a P-type ATPase, is located on human chromosome 18 and isalso mutated in the milder phenotype, benign recurrent intrahepaticcholestasis type 1 (BRIO) and in Greenland familial cholestasis. FIC1protein is located on the canalicular membrane of the hepatocyte butwithin the liver it is mainly expressed in cholangiocytes. P-type ATPaseappears to be an aminophospholipid transporter responsible formaintaining the enrichment of phosphatidylserine andphophatidylethanolamme on the inner leaflet of the plasma membrane incomparison of the outer leaflet. The asymmetric distribution of lipidsin the membrane bilayer plays a protective role against high bile saltconcentrations in the canalicular lumen. The abnormal protein functionmay indirectly disturb the biliary secretion of bile acids. Theanomalous secretion of bile acids/salts leads to hepatocyte bile acidoverload.

PFIC 1 typically presents in infants (e.g., age 6-18 months). Theinfants may show signs of pruritus, jaundice, abdominal distension,diarrhea, malnutrition, and shortened stature. Biochemically,individuals with PFIC 1 have elevated serum transaminases, elevatedbilirubin, elevated serum bile acid levels, and low levels of gammaGT.The individual may also have liver fibrosis. Individuals with PFIC 1typically do not have bile duct proliferation. Most individuals withPFIC 1 will develop end-stage liver disease by 10 years of age. Nomedical treatments have proven beneficial for the long-term treatment ofPFIC 1. In order to reduce extrahepatic symptoms (e.g., malnutrition andfailure to thrive), children are often administered medium chaintriglycerides and fat-soluble vitamins. Ursodiol has not beendemonstrated as effective in individuals with PFIC 1.

PFIC 2

PFIC 2 (also known as, Byler Syndrome or BSEP deficiency) is associatedwith mutations in the ABCB11 gene (also designated BSEP). The ABCB11gene encodes the ATP-dependent canalicular bile salt export pump (BSEP)of human liver and is located on human chromosome 2. BSEP protein,expressed at the hepatocyte canalicular membrane, is the major exporterof primary bile acids/salts against extreme concentration gradients.Mutations in this protein are responsible for the decreased biliary bilesalt secretion described in affected patients, leading to decreased bileflow and accumulation of bile salts inside the hepatocyte with ongoingsevere hepatocellular damage.

PFIC 2 typically presents in infants (e.g., age 6-18 months). Theinfants may show signs of pruritus. Biochemically, individuals with PFIC2 have elevated serum transaminases, elevated bilirubin, elevated serumbile acid levels, and low levels of gammaGT. The individual may alsohave portal inflammation and giant cell hepatitis. Further, individualsoften develop hepatocellular carcinoma. No medical treatments haveproven beneficial for the long-term treatment of PFIC 2. In order toreduce extrahepatic symptoms (e.g., malnutrition and failure to thrive),children are often administered medium chain triglycerides andfat-soluble vitamins. The PFIC 2 patient population accounts forapproximately 60% of the PFIC population.

PFIC 3

PFIC 3 (also known as MDR3 deficiency) is caused by a genetic defect inthe ABCB4 gene (also designated MDR3) located on chromosome 7. Class IIIMultidrug Resistance (MDR3) P-glycoprotein (P-gp), is a phospholipidtranslocator involved in biliary phospholipid (phosphatidylcholine)excretion in the canlicular membrane of the hepatocyte. PFIC 3 resultsfrom the toxicity of bile in which detergent bile salts are notinactivated by phospholipids, leading to bile canaliculi and biliaryepithelium injuries.

PFIC 3 also presents in early childhood. As opposed to PFIC 1 and PFIC2, individuals have elevated gammaGT levels. Individuals also haveportal inflammation, fibrosis, cirrhosis, and massive bile ductproliferation. Individuals may also develop intrahepatic gallstonedisease. Ursodiol has been effective in treating or ameliorating PFIC 3.

Benign Recurrent Intrahepatic Cholestasis (BRIC) BRIC 1

BRIC1 is caused by a genetic defect of the FIC1 protein in thecanalicular membrane of hepatocytes. BRIC1 is typically associated withnormal serum cholesterol and γ-glutamyltranspeptidase levels, butelevated serum bile salts. Residual FIC1 expression and function isassociated with BRIC1. Despite recurrent attacks of cholestasis orcholestatic liver disease, there is no progression to chronic liverdisease in a majority of patients. During the attacks, the patients areseverely jaundiced and have pruritis, steatorrhea, and weight loss. Somepatients also have renal stones, pancreatitis, and diabetes.

BRIC 2

BRIC2 is caused by mutations in ABCB11, leading to defective BSEPexpression and/or function in the canalicular membrane of hepatocytes.

BRIC 3

BRIC3 is related to the defective expression and/or function of MDR3 inthe canalicular membrane of hepatocytes. Patients with MDR3 deficiencyusually display elevated serum γ-glutamyltranspeptidase levels in thepresence of normal or slightly elevated bile acid levels.

Dubin-Johnson Syndrome (DJS)

DJS is characterized by conjugated hyperbilirubinemia due to inheriteddysfunction of MRP2. Hepatic function is preserved in affected patients.Several different mutations have been associated with this condition,resulting either in the complete absence of immunohistochemicallydetectable MRP2 in affected patients or impaired protein maturation andsorting.

Acquired Cholestatic Disease Primary Biliary Cirrhosis (PBC)

PBC is a chronic inflammatory hepatic disorder slowly progressing to endstage liver failure in most of the affected patients. In PBC, theinflammatory process affects predominantly the small bile ducts.

Primary Sclerosing Cholangitis (PSC)

PSC is a chronic inflammatory hepatic disorder slowly progressing to endstage liver failure in most of the affected patients. In PSCinflammation, fibrosis and obstruction of large and medium sized intra-and extrahepatic ductuli is predominant.

PSC is characterized by progressive cholestasis. Cholestasis can oftenlead to severe pruritus which significantly impairs quality of life.

Intrahepatic Cholestasis of Pregnancy (ICP)

ICP is characterized by occurrence of transient cholestasis orcholestatic liver disease in pregnant women typically occurring in thethird trimester of pregnancy, when the circulating levels of estrogensare high. ICP is associated with pruritis and biochemical cholestasis orcholestatic liver disease of varying severity and constitutes a riskfactor for prematurity and intrauterine fetal death. A geneticpredisposition has been suspected based upon the strong regionalclustering, the higher prevalence in female family members of patientswith ICP and the susceptibility of ICP patients to develop intrahepaticcholestasis or cholestatic liver disease under other hormonal challengessuch as oral contraception. A heterogeneous state for an MDR3 genedefect may represent a genetic predisposition.

Gallstone Disease

Gallstone disease is one of the most common and costly of all digestivediseases with a prevalence of up to 17% in Caucasian women. Cholesterolcontaining gallstones are the major form of gallstones andsupersaturation of bile with cholesterol is therefore a prerequisite forgallstone formation. ABCB4 mutations may be involved in the pathogenesisof cholesterol gallstone disease.

Drug Induced Cholestasis

Inhibition of BSEP function by drugs is an important mechanism ofdrug-induced cholestasis, leading to the hepatic accumulation of bilesalts and subsequent liver cell damage. Several drugs have beenimplicated in BSEP inhibition. Most of these drugs, such as rifampicin,cyclosporine, glibenclamide, or troglitazone directly cis-inhibitATP-dependent taurocholate transport in a competitive manner, whileestrogen and progesterone metabolites indirectly trans-inhibits BSEPafter secretion into the bile canaliculus by Mrp2. Alternatively,drug-mediated stimulation of MRP2 can promote cholestasis or cholestaticliver disease by changing bile composition.

Total Parenteral Nutrition Associated Cholestasis

TPNAC is one of the most serious clinical scenarios where cholestasis orcholestatic liver disease occurs rapidly and is highly linked with earlydeath. Infants, who are usually premature and who have had gutresections are dependent upon TPN for growth and frequently developcholestasis or cholestatic liver disease that rapidly progresses tofibrosis, cirrhosis, and portal hypertension, usually before 6 months oflife. The degree of cholestasis or cholestatic liver disease and chanceof survival in these infants have been linked to the number of septicepisodes, likely initiated by recurrent bacterial translocation acrosstheir gut mucosa. Although there are also cholestatic effects from theintravenous formulation in these infants, septic mediators likelycontribute the most to altered hepatic function.

Alagille Syndrome (ALGS)

Alagille syndrome is a genetic disorder that affects the liver and otherorgans. ALGS is also known as syndromic intrahepatic bile duct paucityor arteriohepatic dysplasia. ALGS is a rare genetic disorder in whichbile ducts are abnormally narrow, malfomrmed, and reduced in number,which leads to bile accumulation in the liver and ultimately progressiveliver disease. ALGS is autosomal dominant, caused by mutations in JAG1(>90% of cases) or NOTCH2. The estimated incidence of ALGS is one inevery 30,000 or 50,000 births in the United States and Europe. Inpatients with ALGS, multiple organ systems may be affected by themutation, including the liver, heart, kidneys and central nervoussystem. The accumulation of bile acids prevents the liver from workingproperly to eliminate waste from the bloodstream and leads toprogressive liver disease that ultimately requires liver transplantationin 15% to 47% of patients. Signs and symptoms arising from liver damagein ALGS may include jaundice, pruritus and xanthomas, and decreasedgrowth. The pruritus experienced by patients with ALGS is among the mostsevere in any chronic liver disease and is present in most affectedchildren by the third year of life.

ALGS often presents during infancy (e.g., age 6-18 months) through earlychildhood (e.g., age 3-5 years) and may stabilize after the age of 10.Symptoms may include chronic progressive cholestasis, ductopenia,jaundice, pruritus, xanthomas, congenital heart problems, paucity ofintrahepatic bile ducts, poor linear growth, hormone resistance,posterior embryotoxon, Axenfeld anomaly, retinitis pigmentosa, pupillaryabnormalities, cardiac murmur, atrial septal defect, ventricular septaldefect, patent ductus arteriosus, and Tetralogy of Fallot. Individualsdiagnosed with Alagille syndrome have been treated with ursodiol,hydroxyzine, cholestyramine, rifampicin, and phenobarbitol. Due to areduced ability to absorb fat-soluble vitamins, individuals withAlagille Syndrome are further administered high dose multivitamins.

Biliary Atresia

Biliary atresia is a life-threatening condition in infants in which thebile ducts inside or outside the liver do not have normal openings. Withbiliary atresia, bile becomes trapped, builds up, and damages the liver.The damage leads to scarring, loss of liver tissue, and cirrhosis.Without treatment, the liver eventually fails, and the infant needs aliver transplant to stay alive. The two types of biliary atresia arefetal and perinatal. Fetal biliary atresia appears while the baby is inthe womb. Perinatal biliary atresia is much more common and does notbecome evident until 2 to 4 weeks after birth.

Post-Kasai Biliary Atresia

Biliary atresia is treated with surgery called the Kasai procedure or aliver transplant. The Kasai procedure is usually the first treatment forbiliary atresia. During a Kasai procedure, the pediatric surgeon removesthe infant's damaged bile ducts and brings up a loop of intestine toreplace them. While the Kasai procedure can restore bile flow andcorrect many problems caused by biliary atresia, the surgery doesn'tcure biliary atresia. If the Kasai procedure is not successful, infantsusually need a liver transplant within 1 to 2 years. Even after asuccessful surgery, most infants with biliary atresia slowly developcirrhosis over the years and require a liver transplant by adulthood.Possible complications after the Kasai procedure include ascites,bacterial cholangitis, portal hypertension, and pruritis.

Post Liver Transplantation Biliary Atresia

If the atresia is complete, liver transplantation is the only option.Although liver transplantation is generally successful at treatingbiliary atresia, liver transplantation may have complications such asorgan rejection. Also, a donor liver may not become available. Further,in some patients, liver transplantation may not be successful at curingbiliary atresia.

Xanthoma

Xanthoma is a skin condition associated with cholestatic liver diseases,in which certain fats build up under the surface of the skin.Cholestasis results in several disturbances of lipid metabolismresulting in formation of an abnormal lipid particle in the blood calledlipoprotein X. Lipoprotein X is formed by regurgitation of bile lipidsinto the blood from the liver and does not bind to the LDL receptor todeliver cholesterol to cells throughout the body as does normal LDL.Lipoprotein X increases liver cholesterol production by fivefold andblocks normal removal of lipoprotein particles from the blood by theliver.

General Definitions

Unless defined otherwise, all technical and scientific terms used hereinhave the same meaning as commonly understood by one of ordinary skill inthe art to which this invention belongs.

As used in this specification and the appended claims, the singularforms “a”, “an”, and “the” include plural references unless the contextclearly dictates otherwise. Thus, for example, a reference to “a method”includes one or more methods, and/or steps of the type described hereinand/or which will become apparent to those persons skilled in the artupon reading this disclosure.

The term “baseline” or “pre-administration baseline,” as used herein,refers to information gathered at the beginning of a study or an initialknown value which is used for comparison with later data. A baseline isan initial measurement of a measurable condition that is taken at anearly time point and used for comparison over time to look for changesin the measurable condition. For example, serum bile acid concentrationin a patient before administration of a drug (baseline) and afteradministration of the drug. Baseline is an observation or value thatrepresents the normal or beginning level of a measurable quality, usedfor comparison with values representing response to intervention or anenvironmental stimulus. The baseline is time “zero”, before participantsin a study receive an experimental agent or intervention, or negativecontrol. For example, “baseline” may refer in some instances 1) to thestate of a measurable quantity just prior to the initiation of aclinical study or 2) the state of a measurable quantity just prior toaltering a dosage level or composition administered to a patient from afirst dosage level or composition to a second dosage level orcomposition.

The terms “level” and “concentration,” as used herein, are usedinterchangeably. For example, “high serum levels of bilirubin” mayalternatively be phrased “high serum concentrations of bilirubin.”

The terms “normalized” or “normal range,” as used herein, indicatesage-specific values that are within a range corresponding to a healthyindividual (i.e., normal or normalized values). For example, the phrase“serum bilirubin concentratins were normalized within three weeks” meansthat serum bilirubin concentrations fell within a range known in the artto correspond to that of a healthy individual (i.e., within a normal andnot e.g. an elevated range) within three weeks. In various embodiments,a normalized serum bilirubin concentration is from about 0.1 mg/dL toabout 1.2 mg/dL. In various embodiments, a normalized serum bile acidconcentration is from about 0 μmol/L to about 25 μmol/L.

The terms “ITCHRO(OBS)” and “ITCHRO” (alternatively, “ItchRO(Pt)”) asused herein, are used interchangeably with the qualification that theITCHRO(OBS) scale is used to measure severity of pruritus in childrenunder the age of 18 and the ITCHRO scale is used to measure severity ofpruritus in adults of at least 18 years of age. Therefore, whereITCHRO(OBS) scale is mentioned with regard to an adult patient, theITCHRO scale is the scale being indicated. Similarly, whenever theITCHRO scale is mentioned with regard to a pediatric patient, theITCHRO(OBS) scale is usually the scale being indicated (some olderchildren were permitted to report their own scores as ITCHRO scores. TheITCHRO(OBS) scale ranges from 0 to 4 and the ITCHRO scale ranges from 0to 10.

The term “bile acid” or “bile acids,” as used herein, includes steroidacids (and/or the carboxylate anion thereof), and salts thereof, foundin the bile of an animal (e.g., a human), including, by way ofnon-limiting example, cholic acid, cholate, deoxycholic acid,deoxycholate, hyodeoxycholic acid, hyodeoxycholate, glycocholic acid,glycocholate, taurocholic acid, taurocholate, chenodeoxycholic acid,ursodeoxycholic acid, ursodiol, a tauroursodeoxycholic acid, aglycoursodeoxycholic acid, a 7-B-methyl cholic acid, a methyllithocholic acid, chenodeoxycholate, lithocholic acid, lithocolate, andthe like. Taurocholic acid and/or taurocholate are referred to herein asTCA. Any reference to a bile acid used herein includes reference to abile acid, one and only one bile acid, one or more bile acids, or to atleast one bile acid. Therefore, the terms “bile acid,” “bile salt,”“bile acid/salt,” “bile acids,” “bile salts,” and “bile acids/salts”are, unless otherwise indicated, utilized interchangeably herein. Anyreference to a bile acid used herein includes reference to a bile acidor a salt thereof. Furthermore, pharmaceutically acceptable bile acidesters are optionally utilized as the “bile acids” described herein,e.g., bile acids/salts conjugated to an amino acid (e.g., glycine ortaurine). Other bile acid esters include, e.g., substituted orunsubstituted alkyl ester, substituted or unsubstituted heteroalkylesters, substituted or unsubstituted aryl esters, substituted orunsubstituted heteroaryl esters, or the like. For example, the term“bile acid” includes cholic acid conjugated with either glycine ortaurine: glycocholate and taurocholate, respectively (and saltsthereof). Any reference to a bile acid used herein includes reference toan identical compound naturally or synthetically prepared. Furthermore,it is to be understood that any singular reference to a component (bileacid or otherwise) used herein includes reference to one and only one,one or more, or at least one of such components. Similarly, any pluralreference to a component used herein includes reference to one and onlyone, one or more, or at least one of such components, unless otherwisenoted.

The term “subject”, “patient”, “participant”, or “individual” are usedinterchangeably herein and refer to mammals and non-mammals, e.g.,suffering from a disorder described herein. Examples of mammals include,but are not limited to, any member of the mammalian class: humans,non-human primates such as chimpanzees, and other apes and monkeyspecies; farm animals such as cattle, horses, sheep, goats, swine;domestic animals such as rabbits, dogs, and cats; laboratory animalsincluding rodents, such as rats, mice and guinea pigs, and the like.Examples of non-mammals include, but are not limited to, birds, fish andthe like. In one embodiment of the methods and compositions providedherein, the mammal is a human.

The term “about,” as used herein, includes any value that is within 10%of the described value.

The term “composition,” as used herein includes the disclosure of both acomposition and a composition administered in a method as describedherein. Furthermore, in some embodiments, the composition of the presentinvention is or comprises a “formulation,” an oral dosage form or arectal dosage form as described herein.

The terms “treat,” “treating” or “treatment,” and other grammaticalequivalents as used herein, include alleviating, inhibiting or reducingsymptoms, reducing or inhibiting severity of, reducing incidence of,reducing or inhibiting recurrence of, delaying onset of, delayingrecurrence of, abating or ameliorating a disease or condition symptoms,ameliorating the underlying causes of symptoms, inhibiting the diseaseor condition, e.g., arresting the development of the disease orcondition, relieving the disease or condition, causing regression of thedisease or condition, relieving a condition caused by the disease orcondition, or stopping the symptoms of the disease or condition. Theterms further include achieving a therapeutic benefit. By therapeuticbenefit is meant eradication or amelioration of the underlying disorderbeing treated, and/or the eradication or amelioration of one or more ofthe physiological symptoms associated with the underlying disorder suchthat an improvement is observed in the patient.

The terms “effective amount” or “therapeutically effective amount” asused herein, refer to a sufficient amount of at least one agent (e.g., atherapeutically active agent) being administered which achieve a desiredresult in a subject or individual, e.g., to relieve to some extent oneor more symptoms of a disease or condition being treated. In certaininstances, the result is a reduction and/or alleviation of the signs,symptoms, or causes of a disease, or any other desired alteration of abiological system. In certain instances, an “effective amount” fortherapeutic uses is the amount of the composition comprising an agent asset forth herein required to provide a clinically significant decreasein a disease. An appropriate “effective” amount in any individual caseis determined using any suitable technique, such as a dose escalationstudy. In some embodiments, a “therapeutically effective amount,” or an“effective amount” of an ASBTI refers to a sufficient amount of an ASBTIto treat cholestasis or a cholestatic liver disease in a subject orindividual.

The terms “administer,” “administering”, “administration,” and the like,as used herein, refer to the methods that may be used to enable deliveryof agents or compositions to the desired site of biological action.These methods include, but are not limited to oral routes, intraduodenalroutes, parenteral injection (including intravenous, subcutaneous,intraperitoneal, intramuscular, intravascular or infusion), topical andrectal administration. Administration techniques that are optionallyemployed with the agents and methods described herein are found insources e.g., Goodman and Gilman, The Pharmacological Basis ofTherapeutics, current ed.; Pergamon; and Remington's, PharmaceuticalSciences (current edition), Mack Publishing Co., Easton, Pa., all ofwhich are incorporated herein by reference in their entirety for allpurposes. In certain embodiments, the agents and compositions describedherein are administered orally.

The term “ASBT inhibitor” refers to a compound that inhibits apicalsodium-dependent bile transport or any recuperative bile salt transport.The term Apical Sodium-dependent Bile Transporter (ASBT) is usedinterchangeably with the term Ileal Bile Acid Transporter (IBAT).

The phrase “pharmaceutically acceptable”, as used in connection withcompositions of the invention, refers to molecular entities and otheringredients of such compositions that are physiologically tolerable anddo not typically produce untoward reactions when administered to amammal (e.g., a human). Preferably, as used herein, the term“pharmaceutically acceptable” means approved by a regulatory agency ofthe Federal or a state government or listed in the U.S. Pharmacopeia orother generally recognized pharmacopeia for use in mammals, and moreparticularly in humans.

In various embodiments, pharmaceutically acceptable salts describedherein include, by way of non-limiting example, a nitrate, chloride,bromide, phosphate, sulfate, acetate, hexafluorophosphate, citrate,gluconate, benzoate, propionate, butyrate, subsalicylate, maleate,laurate, malate, fumarate, succinate, tartrate, amsonate, pamoate,p-tolunenesulfonate, mesylate and the like. Furthermore,pharmaceutically acceptable salts include, by way of non-limitingexample, alkaline earth metal salts (e.g., calcium or magnesium), alkalimetal salts (e.g., sodium-dependent or potassium), ammonium salts andthe like.

Bile Acid

Bile contains water, electrolytes and a numerous organic moleculesincluding bile acids, cholesterol, phospholipids and bilirubin. Bile issecreted from the liver and stored in the gall bladder, and upon gallbladder contraction, due to ingestion of a fatty meal, bile passesthrough the bile duct into the intestine. Bile acids/salts are criticalfor digestion and absorption of fats and fat-soluble vitamins in thesmall intestine. Adult humans produce 400 to 800 mL of bile daily. Thesecretion of bile can be considered to occur in two stages. Initially,hepatocytes secrete bile into canaliculi, from which it flows into bileducts and this hepatic bile contains large quantities of bile acids,cholesterol and other organic molecules. Then, as bile flows through thebile ducts, it is modified by addition of a watery, bicarbonate-richsecretion from ductal epithelial cells. Bile is concentrated, typicallyfive-fold, during storage in the gall bladder.

The flow of bile is lowest during fasting, and a majority of that isdiverted into the gallbladder for concentration. When chyme from aningested meal enters the small intestine, acid and partially digestedfats and proteins stimulate secretion of cholecystokinin and secretin,both of which are important for secretion and flow of bile.Cholecystokinin (cholecysto=gallbladder and kinin=movement) is a hormonewhich stimulates contractions of the gallbladder and common bile duct,resulting in delivery of bile into the gut. The most potent stimulus forrelease of cholecystokinin is the presence of fat in the duodenum.Secretin is a hormone secreted in response to acid in the duodenum, andit simulates biliary duct cells to secrete bicarbonate and water, whichexpands the volume of bile and increases its flow out into theintestine.

Bile acids/salts are derivatives of cholesterol. Cholesterol, ingestedas part of the diet or derived from hepatic synthesis, are convertedinto bile acids/salts in the hepatocyte. Examples of such bileacids/salts include cholic and chenodeoxycholic acids, which are thenconjugated to an amino acid (such as glycine or taurine) to yield theconjugated form that is actively secreted into cannaliculi. The mostabundant of the bile salts in humans are cholate and deoxycholate, andthey are normally conjugated with either glycine or taurine to giveglycocholate or taurocholate respectively.

Free cholesterol is virtually insoluble in aqueous solutions, however inbile it is made soluble by the presence of bile acids/salts and lipids.Hepatic synthesis of bile acids/salts accounts for the majority ofcholesterol breakdown in the body. In humans, roughly 500 mg ofcholesterol are converted to bile acids/salts and eliminated in bileevery day. Therefore, secretion into bile is a major route forelimination of cholesterol. Large amounts of bile acids/salts aresecreted into the intestine every day, but only relatively smallquantities are lost from the body. This is because approximately 95% ofthe bile acids/salts delivered to the duodenum are absorbed back intoblood within the ileum, by a process is known as “EnterohepaticRecirculation”.

Venous blood from the ileum goes straight into the portal vein, andhence through the sinusoids of the liver. Hepatocytes extract bileacids/salts very efficiently from sinusoidal blood, and little escapesthe healthy liver into systemic circulation. Bile acids/salts are thentransported across the hepatocytes to be resecreted into canaliculi. Thenet effect of this enterohepatic recirculation is that each bile saltmolecule is reused about 20 times, often two or three times during asingle digestive phase. Bile biosynthesis represents the major metabolicfate of cholesterol, accounting for more than half of the approximate800 mg/day of cholesterol that an average adult uses up in metabolicprocesses. In comparison, steroid hormone biosynthesis consumes onlyabout 50 mg of cholesterol per day. Much more that 400 mg of bile saltsis required and secreted into the intestine per day, and this isachieved by re-cycling the bile salts. Most of the bile salts secretedinto the upper region of the small intestine are absorbed along with thedietary lipids that they emulsified at the lower end of the smallintestine. They are separated from the dietary lipid and returned to theliver for re-use. Recycling thus enables 20-30 g of bile salts to besecreted into the small intestine each day.

Bile acids/salts are amphipathic, with the cholesterol-derived portioncontaining both hydrophobic (lipid soluble) and polar (hydrophilic)moieties while the amino acid conjugate is generally polar andhydrophilic. This amphipathic nature enables bile acids/salts to carryout two important functions: emulsification of lipid aggregates andsolubilization and transport of lipids in an aqueous environment. Bileacids/salts have detergent action on particles of dietary fat whichcauses fat globules to break down or to be emulsified. Emulsification isimportant since it greatly increases the surface area of fat availablefor digestion by lipases which cannot access the inside of lipiddroplets. Furthermore, bile acids/salts are lipid carriers and are ableto solubilize many lipids by forming micelles and are critical fortransport and absorption of the fat-soluble vitamins.

The term “non-systemic” or “minimally absorbed,” as used herein, refersto low systemic bioavailability and/or absorption of an administeredcompound. In some embodiments, a non-systemic compound is a compoundthat is substantially not absorbed systemically. In some embodiments,ASBTI compositions described herein deliver the ASBTI to the distalileum, colon, and/or rectum and not systemically (e.g., a substantialportion of the ASBTI is not systemically absorbed. In some embodiments,the systemic absorption of anon-systemic compound is <0.1%, <0.3%,<0.5%, <0.6%, <0.7%, <0.8%, <0.9%, <1%, <1.5%, <2%, <3%, or <5% of theadministered dose (wt. % or mol %). In some embodiments, the systemicabsorption of a non-systemic compound is <10% of the administered dose.In some embodiments, the systemic absorption of a non-systemic compoundis <15% of the administered dose. In some embodiments, the systemicabsorption of a non-systemic compound is <25% of the administered dose.In an alternative approach, a non-systemic ASBTI is a compound that haslower systemic bioavailability relative to the systemic bioavailabilityof a systemic ASBTI (e.g., compound 100A, 100C). In some embodiments,the bioavailability of a non-systemic ASBTI described herein is <30%,<40%, <50%, <60%, or <70% of the bioavailability of a systemic ASBTI(e.g., compound 100A, 100C).

In another alternative approach, compositions described herein areformulated to deliver <10% of the administered dose of the ASBTIsystemically. In some embodiments, the compositions described herein areformulated to deliver <20% of the administered dose of the ASBTIsystemically. In some embodiments, the compositions described herein areformulated to deliver <30% of the administered dose of the ASBTIsystemically. In some embodiments, the compositions described herein areformulated to deliver <40% of the administered dose of the ASBTIsystemically. In some embodiments, the compositions described herein areformulated to deliver <50% of the administered dose of the ASBTIsystemically. In some embodiments, the compositions described herein areformulated to deliver <60% of the administered dose of the ASBTIsystemically. In some embodiments, the compositions described herein areformulated to deliver <70% of the administered dose of the ASBTIsystemically. In some embodiments, systemic absorption is determined inany suitable manner, including the total circulating amount, the amountcleared after administration, or the like.

The term “optionally substituted” or “substituted” means that thereferenced group substituted with one or more additional group(s). Incertain embodiments, the one or more additional group(s) areindividually and independently selected from amide, ester, alkyl,cycloalkyl, heteroalkyl, aryl, heteroaryl, heteroalicyclic, hydroxy,alkoxy, aryloxy, alkylthio, arylthio, alkylsulfoxide, arylsulfoxide,ester, alkylsulfone, arylsulfone, cyano, halo, alkoyl, alkoyloxo,isocyanato, thiocyanato, isothiocyanato, nitro, haloalkyl, haloalkoxy,fluoroalkyl, amino, alkyl-amino, dialkyl-amino, amido.

An “alkyl” group refers to an aliphatic hydrocarbon group. Reference toan alkyl group includes “saturated alkyl” and/or “unsaturated alkyl”.The alkyl group, whether saturated or unsaturated, includes branched,straight chain, or cyclic groups. By way of example only, alkyl includesmethyl, ethyl, propyl, iso-propyl, n-butyl, iso-butyl, sec-butyl,t-butyl, pentyl, iso-pentyl, neo-pentyl, and hexyl. In some embodiments,alkyl groups include, but are in no way limited to, methyl, ethyl,propyl, isopropyl, butyl, isobutyl, tertiary butyl, pentyl, hexyl,ethenyl, propenyl, butenyl, cyclopropyl, cyclobutyl, cyclopentyl,cyclohexyl, and the like. A “lower alkyl” is a C₁-C₆ alkyl. A“heteroalkyl” group substitutes any one of the carbons of the alkylgroup with a heteroatom having the appropriate number of hydrogen atomsattached (e.g., a CH₂ group to an NH group or an O group).

The term “alkylene” refers to a divalent alkyl radical. Any of the abovementioned monovalent alkyl groups may be an alkylene by abstraction of asecond hydrogen atom from the alkyl. In one aspect, an alkelene is aC₁-C₁₀alkylene. In another aspect, an alkylene is a C₁-C₆alkylene.Typical alkylene groups include, but are not limited to, —CH₂—,—CH(CH₃)—, —C(CH₃)₂—, —CH₂CH₂—, —CH₂CH(CH₃)—, —CH₂C(CH₃)₂—, —CH₂CH₂CH₂—,—CH₂CH₂CH₂CH₂—, —CH₂CH₂CH₂CH₂CH₂—, —CH₂CH₂CH₂CH₂CH₂CH₂—, and the like.

An “alkoxy” group refers to a (alkyl)O— group, where alkyl is as definedherein.

The term “alkylamine” refers to the —N(alkyl)_(x)H_(y) group, whereinalkyl is as defined herein and x and y are selected from the group x=1,y=1 and x=2, y=0. When x=2, the alkyl groups, taken together with thenitrogen to which they are attached, optionally form a cyclic ringsystem.

An “amide” is a chemical moiety with formula —C(O)NHR or —NHC(O)R, whereR is selected from alkyl, cycloalkyl, aryl, heteroaryl (bonded through aring carbon) and heteroalicyclic (bonded through a ring carbon).

The term “ester” refers to a chemical moiety with formula —C(═O)OR,where R is selected from the group consisting of alkyl, cycloalkyl,aryl, heteroaryl and heteroalicyclic.

As used herein, the term “aryl” refers to an aromatic ring wherein eachof the atoms forming the ring is a carbon atom. Aryl rings describedherein include rings having five, six, seven, eight, nine, or more thannine carbon atoms. Aryl groups are optionally substituted. Examples ofaryl groups include, but are not limited to phenyl, and naphthalenyl.

The term “aromatic” refers to a planar ring having a delocalizedπ-electron system containing 4n+2 π electrons, where n is an integer.Aromatic rings can be formed from five, six, seven, eight, nine, ten, ormore than ten atoms. Aromatics are optionally substituted. The term“aromatic” includes both carbocyclic aryl (“aryl”, e.g., phenyl) andheterocyclic aryl (or “heteroaryl” or “heteroaromatic”) groups (e.g.,pyridine). The term includes monocyclic or fused-ring polycyclic (i.e.,rings which share adjacent pairs of carbon atoms) groups.

The term “cycloalkyl” refers to a monocyclic or polycyclic non-aromaticradical, wherein each of the atoms forming the ring (i.e. skeletalatoms) is a carbon atom. In various embodiments, cycloalkyls aresaturated, or partially unsaturated. In some embodiments, cycloalkylsare fused with an aromatic ring. Cycloalkyl groups include groups havingfrom 3 to 10 ring atoms. Illustrative examples of cycloalkyl groupsinclude, but are not limited to, the following moieties:

and the like. Monocyclic cycloalkyls include, but are not limited to,cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, cycloheptyl, andcyclooctyl.

The term “heterocyclo” refers to heteroaromatic and heteroalicyclicgroups containing one to four ring heteroatoms each selected from O, Sand N. In certain instances, each heterocyclic group has from 4 to 10atoms in its ring system, and with the proviso that the ring of saidgroup does not contain two adjacent O or S atoms. Non-aromaticheterocyclic groups include groups having 3 atoms in their ring system,but aromatic heterocyclic groups must have at least 5 atoms in theirring system. The heterocyclic groups include benzo-fused ring systems.An example of a 3-membered heterocyclic group is aziridinyl (derivedfrom aziridine). An example of a 4-membered heterocyclic group isazetidinyl (derived from azetidine). An example of a 5-memberedheterocyclic group is thiazolyl. An example of a 6-membered heterocyclicgroup is pyridyl, and an example of a 10-membered heterocyclic group isquinolinyl. Examples of non-aromatic heterocyclic groups arepyrrolidinyl, tetrahydrofuranyl, dihydrofuranyl, tetrahydrothienyl,tetrahydropyranyl, dihydropyranyl, tetrahydrothiopyranyl, piperidino,morpholino, thiomorpholino, thioxanyl, piperazinyl, aziridinyl,azetidinyl, oxetanyl, thietanyl, homopiperidinyl, oxepanyl, thiepanyl,oxazepinyl, diazepinyl, thiazepinyl, 1,2,3,6-tetrahydropyridinyl,2-pyrrolinyl, 3-pyrrolinyl, indolinyl, 2H-pyranyl, 4H-pyranyl, dioxanyl,1,3-dioxolanyl, pyrazolinyl, dithianyl, dithiolanyl, dihydropyranyl,dihydrothienyl, dihydrofuranyl, pyrazolidinyl, imidazolinyl,imidazolidinyl, 3-azabicyclo[3.1.0]hexanyl, 3-azabicyclo[4.1.0]heptanyl,3H-indolyl and quinolizinyl. Examples of aromatic heterocyclic groupsare pyridinyl, imidazolyl, pyrimidinyl, pyrazolyl, triazolyl, pyrazinyl,tetrazolyl, furyl, thienyl, isoxazolyl, thiazolyl, oxazolyl,isothiazolyl, pyrrolyl, quinolinyl, isoquinolinyl, indolyl,benzimidazolyl, benzofuranyl, cinnolinyl, indazolyl, indolizinyl,phthalazinyl, pyridazinyl, triazinyl, isoindolyl, pteridinyl, purinyl,oxadiazolyl, thiadiazolyl, furazanyl, benzofurazanyl, benzothiophenyl,benzothiazolyl, benzoxazolyl, quinazolinyl, quinoxalinyl,naphthyridinyl, and furopyridinyl.

The terms “heteroaryl” or, alternatively, “heteroaromatic” refers to anaryl group that includes one or more ring heteroatoms selected fromnitrogen, oxygen and sulfur. An N-containing “heteroaromatic” or“heteroaryl” moiety refers to an aromatic group in which at least one ofthe skeletal atoms of the ring is a nitrogen atom. In certainembodiments, heteroaryl groups are monocyclic or polycyclic.Illustrative examples of heteroaryl groups include the followingmoieties:

and the like.

A “heteroalicyclic” group or “heterocyclo” group refers to a cycloalkylgroup, wherein at least one skeletal ring atom is a heteroatom selectedfrom nitrogen, oxygen and sulfur. In various embodiments, the radicalsare with an aryl or heteroaryl. Illustrative examples of heterocyclogroups, also referred to as non-aromatic heterocycles, include:

and the like. The term heteroalicyclic also includes all ring forms ofthe carbohydrates, including but not limited to the monosaccharides, thedisaccharides and the oligosaccharides.

The term “halo” or, alternatively, “halogen” means fluoro, chloro, bromoand iodo.

The terms “haloalkyl,” and “haloalkoxy” include alkyl and alkoxystructures that are substituted with one or more halogens. Inembodiments, where more than one halogen is included in the group, thehalogens are the same or they are different. The terms “fluoroalkyl” and“fluoroalkoxy” include haloalkyl and haloalkoxy groups, respectively, inwhich the halo is fluorine.

The term “heteroalkyl” include optionally substituted alkyl, alkenyl andalkynyl radicals which have one or more skeletal chain atoms selectedfrom an atom other than carbon, e.g., oxygen, nitrogen, sulfur,phosphorus, silicon, or combinations thereof. In certain embodiments,the heteroatom(s) is placed at any interior position of the heteroalkylgroup.

Examples include, but are not limited to, —CH₂—O—CH₃, —CH₂—CH₂—O—CH₃,—CH₂—NH—CH₃, —CH₂—CH₂—NH—CH₃, —CH₂—N(CH₃)—CH₃, —CH₂—CH₂—NH—CH₃,—CH₂—CH₂—N(CH₃)—CH₃, —CH₂—S—CH₂—CH₃, —CH₂—CH₂, —S(O)—CH₃,—CH₂—CH₂—S(O)₂—CH₃, —CH═CH—O—CH₃, —Si(CH₃)₃, —CH₂—CH═N—OCH₃, and—CH═CH—N(CH₃)—CH₃. In some embodiments, up to two heteroatoms areconsecutive, such as, by way of example, —CH₂—NH—OCH₃ and—CH₂—O—Si(CH₃)₃.

A “cyano” group refers to a —CN group.

An “isocyanato” group refers to a —NCO group.

A “thiocyanato” group refers to a —CNS group.

An “isothiocyanato” group refers to a —NCS group.

“Alkoyloxy” refers to a RC(═O)O— group.

“Alkoyl” refers to a RC(═O)— group.

The term “modulate,” as used herein refers to having some affect on(e.g., increasing, enhancing or maintaining a certain level).

The term “optionally substituted” or “substituted” means that thereferenced group may be substituted with one or more additional group(s)individually and independently selected from C₁-C₆alkyl,C₃-C₈cycloalkyl, aryl, heteroaryl, C₂-C₆heteroalicyclic, hydroxy,C₁-C₆alkoxy, aryloxy, arylalkoxy, aralkyloxy, arylalkyloxy,C₁-C₆alkylthio, arylthio, C₁-C₆alkylsulfoxide, arylsulfoxide,C₁-C₆alkylsulfone, arylsulfone, cyano, halo, C₂-C₈acyl, C₂-C₈acyloxy,nitro, C₁-C₆haloalkyl, C₁-C₆fluoroalkyl, and amino, includingC₁-C₆alkylamino, and the protected derivatives thereof. By way ofexample, an optional substituents may be L^(s)R^(s), wherein each L^(s)is independently selected from a bond, —O—, —C(═O)—, —S—, —S(═O)—,—S(═O)₂—, —NH—, —NHC(═O)—, —C(═O)NH—, S(═O)₂NH—, —NHS(═O)₂—, —OC(═O)NH—,—NHC(═O)O—, —(C₁-C₆alkyl)-, or —(C₂-C₆alkenyl)-; and each R^(S) isindependently selected from H, (C₁-C₄alkyl), (C₃-C₈cycloalkyl),heteroaryl, aryl, and C₁-C₆heteroalkyl. Optionally substitutednon-aromatic groups may be substituted with one or more oxo (═O). Theprotecting groups that may form the protective derivatives of the abovesubstituents are known to those of skill in the art and may be found inreferences such as Greene and Wuts, above. In some embodiments, alkylgroups described herein are optionally substituted with an O that isconnected to two adjacent carbon atoms (i.e., forming an epoxide).

ASBT Inhibitors

In various embodiments of methods of the present invention, ASBTinhibitors are administered to a subject. ASBT inhibitors (ASBTIs)reduce or inhibit bile acid recycling in the distal gastrointestinal(GI) tract, including the distal ileum, the colon and/or the rectum.Inhibition of the apical sodium-dependent bile acid transport interruptsthe enterohepatic circulation of bile acids and results in more bileacids being excreted in the feces, see FIG. 1, leading to lower levelsof bile acids systemically, thereby reducing bile acid mediated liverdamage and related effects and complications. In certain embodiments,the ASBTIs are systemically absorbed. In certain embodiments, the ASBTIsare not systemically absorbed. In some embodiments, ASBTIs describedherein are modified or substituted (e.g., with a -L-K group) to benon-systemic. In certain embodiments, any ASBT inhibitor is modified orsubstituted with one or more charged groups (e.g., K) and optionally,one or more linker (e.g., L), wherein L and K are as defined herein.

In some embodiments, an ASBTI suitable for the methods described hereinis a compound of Formula I:

wherein:

R¹ is a straight chained C₁₋₆ alkyl group;

R² is a straight chained C₁₋₆ alkyl group;

R³ is hydrogen or a group OR¹¹ in which R¹¹ is hydrogen, optionallysubstituted C₁₋₆ alkyl or a C₁₋₆ alkylcarbonyl group;

R⁴ is pyridyl or optionally substituted phenyl or -L_(z)-K_(z); whereinz is 1, 2 or 3; each L is independently a substituted or unsubstitutedalkyl, a substituted or unsubstituted heteroalkyl, a substituted orunsubstituted alkoxy, a substituted or unsubstituted aminoalkyl group, asubstituted or unsubstituted aryl, a substituted or unsubstitutedheteroaryl, a substituted or unsubstituted cycloalkyl, or a substitutedor unsubstituted heterocycloalkyl; each K is a moiety that preventssystemic absorption;

R⁵, R⁶, R⁷ and R⁸ are the same or different and each is selected fromhydrogen, halogen, cyano, R⁵-acetylide, OR¹⁵, optionally substitutedC₁₋₆ alkyl, COR¹⁵, CH(OH)R¹⁵, S(O)_(n)R¹⁵, P(O)(OR¹⁵)₂, OCOR¹⁵, OCF3,OCN, SCN, NHCN, CH₂OR¹⁵, CHO, (CH₂)_(p)CN, CONR¹²R¹³, (CH₂)_(p)CO₂R¹⁵,(CH₂)_(p)NR¹²R¹³, CO₂R¹⁵, NHCOCF₃, NHSO₂R¹⁵, OCH₂OR¹⁵, OCH═CHR¹⁵,O(CH₂CH₂O)_(n)R¹⁵, O(CH₂)_(p)SO₃R¹⁵, O(CH₂)_(p)NR¹²R¹³,O(CH₂)_(p)N⁺R¹²R¹³R¹⁴ and —W—R³¹, wherein W is O or NH and R³¹ isselected from

wherein p is an integer from 1-4, n is an integer from 0-3 and, R¹²,R¹³, R¹⁴ and R¹⁵ are independently selected from hydrogen and optionallysubstituted C₁₋₆ alkyl; or

R⁶ and R⁷ are linked to form a group

wherein R¹² and R¹³ are as hereinbefore defined and m is 1 or 2; and

R⁹ and R¹⁰ are the same or different and each is selected from hydrogenor C₁₋₆ alkyl; and

salts, solvates and physiologically functional derivatives thereof.

In some embodiments of the methods, the compound of Formula I is acompound

wherein

R¹ is a straight chained C₁₋₆ alkyl group;

R² is a straight chained C₁₋₆ alkyl group;

R³ is hydrogen or a group OR¹¹ in which R¹¹ is hydrogen, optionallysubstituted C₁₋₆ alkyl or a C₁₋₆ alkylcarbonyl group;

R⁴ is optionally substituted phenyl;

R⁵, R⁶ and R⁸ are independently selected from hydrogen, C₁₋₄ alkyloptionally substituted by fluorine, C₁₋₄ alkoxy, halogen, or hydroxy;

R⁷ is selected from halogen, cyano, R¹⁵-acetylide, OR¹⁵, optionallysubstituted C₁₋₆ alkyl, COR¹⁵, CH(OH)R¹⁵, S(O)_(n)R¹⁵, P(O)(OR¹⁵)₂,OCOR¹⁵, OCF₃, OCN, SCN, HNCN, CH₂OR¹⁵, CHO, (CH₂)_(p)CN, CONR¹²R¹³,(CH₂)_(p)CO₂R¹⁵, (CH₂)_(p)NR¹²R¹³, CO₂R¹, NHCOCF₃, NHSO₂R¹⁵, OCH₂OR¹⁵,OCH═CHR¹⁵, O(CH₂CH₂O)_(p)R¹⁵, O(CH₂)_(p)SO₃R¹⁵, O(CH₂)_(p)NR¹²R¹³ andO(CH₂)_(p)N⁺R¹²R¹³R¹⁴;

wherein n, p and R¹² to R¹⁵ are as hereinbefore defined;

with the proviso that at least two of R⁵ to R⁸ are not hydrogen; and

salts solvates and physiologically functional derivatives thereof.

In some embodiments of the methods described herein, the compound ofFormula I is a compound

wherein

R¹ is a straight chained C₁₋₆ alkyl group;

R² is a straight chained C₁₋₆ alkyl group;

R³ is hydrogen or a group OR¹¹ in which R¹¹ is hydrogen, optionallysubstituted C₁₋₆ alkyl or a C₁₋₆ alkylcarbonyl group;

R⁴ is un-substituted phenyl;

R⁵ is hydrogen or halogen;

R⁶ and R⁸ are independently selected from hydrogen, C₁₋₄ alkyloptionally substituted by fluorine, C₁₋₄ alkoxy, halogen, or hydroxy;

R⁷ is selected from OR¹⁵, S(O)_(n)R¹⁵, OCOR¹⁵, OCF₃, OCN, SCN, CHO,OCH₂OR¹⁵, OCH═CHR¹⁵, O(CH₂CH₂O)_(n)R¹⁵, O(CH₂)_(p)SO₃R¹⁵,O(CH₂)_(p)NR¹²R¹³ and O(CH₂)_(p)N⁺R¹²R¹³R¹⁴ wherein p is an integer from1-4, n is an integer from 0-3, and R¹², R¹³, R¹⁴, and R¹⁵ areindependently selected from hydrogen and optionally substituted C₁₋₆alkyl;

R⁹ and R¹⁰ are the same or different and each is selected from hydrogenor C₁₋₆ alkyl; and

salts, solvates and physiologically functional derivatives thereof.

In some embodiments of the methods, wherein the compound of Formula I isa compound

wherein

R¹ is methyl, ethyl or n-propyl;

R² is methyl, ethyl, n-propyl, n-butyl or n-pentyl;

R³ is hydrogen or a group OR¹¹ in which R¹¹ is hydrogen, optionallysubstituted C₁₋₆ alkyl or a C₁₋₆ alkylcarbonyl group;

R⁴ is un-substituted phenyl;

R⁵ is hydrogen;

R⁶ and R⁸ are independently selected from hydrogen, C₁₋₄ alkyloptionally substituted by fluorine, C₁₋₄ alkoxy, halogen, or hydroxy;

R⁷ is selected from OR¹⁵, S(O)_(n)R¹⁵, OCOR¹⁵, OCF₃, OCN, SCN, CHO,OCH₂OR¹⁵, OCH═CHR¹⁵, O(CH₂CH₂O)_(n)R¹⁵, O(CH₂)_(p)SO₃R¹⁵,O(CH₂)_(p)NR¹²R¹³ and O(CH₂)_(p)N⁺R¹²R¹³R¹⁴ wherein p is an integer from1-4, n is an integer from 0-3, and R¹², R¹³, R¹⁴, and R¹⁵ areindependently selected from hydrogen and optionally substituted C₁₋₆alkyl;

R⁹ and R¹⁰ are the same or different and each is selected from hydrogenor C₁₋₆ alkyl; and salts, solvates and physiologically functionalderivatives thereof.

In some embodiments of the methods, the compound of Formula I is acompound

wherein

R¹ is methyl, ethyl or n-propyl;

R² is methyl, ethyl, n-propyl, n-butyl or n-pentyl;

R³ is hydrogen or a group OR₁₁ in which R¹¹ is hydrogen, optionallysubstituted C₁₋₆ alkyl or a C₁₋₆ alkylcarbonyl group;

R⁴ is un-substituted phenyl;

R⁵ is hydrogen;

R⁶ is C₁₋₄ alkoxy, halogen, or hydroxy;

R⁷ is OR¹⁵, wherein R¹⁵ is hydrogen or optionally substituted C₁₋₆alkyl;

R⁸ is hydrogen or halogen;

R⁹ and R¹⁰ are the same or different and each is selected from hydrogenor C₁₋₆ alkyl; and salts, solvates and physiologically functionalderivatives thereof.

In some embodiments of the methods, the compound of Formula I is(3R,5R)-3-Butyl-3-ethyl-2,3,4,5-tetrahydro-7,8-dimethoxy-5-phenyl-1,4-benzothiazepine1,1-dioxide;(3R,5R)-3-Butyl-3-ethyl-2,3,4,5-tetrahydro-7,8-dimethoxy-5-phenyl-1,4-benzothiazepin-4-ol1,1-dioxide;(±)-Trans-3-butyl-3-ethyl-2,3,4,5-tetrahydro-7,8-dimethoxy-5-phenyl-1,4-benzothiazepine1,1-dioxide;(±)-Trans-3-butyl-3-ethyl-2,3,4,5-tetrahydro-7,8-dimethoxy-5-phenyl-1,4,-benzothiazepin-4-ol1,1-dioxide;(3R,5R)-7-Bromo-3-butyl-3-ethyl-2,3,4,5-tetrahydro-8-methoxy-5-phenyl-1,4-benzothiazepine1,1-dioxide;(3R,5R)-7-Bromo-3-butyl-3-ethyl-2,3,4,5-tetrahydro-8-methoxy-5-phenyl-1,4-benxothiaxepin-4-ol1,1-dioxide; (3R,5R)-3-Butyl-3-ethyl-2,3,4,5-tetrahydro-5-phenyl-1,4-benzothiazepine-7,8-diol 1,1-dioxide;(3R,5R)-3-Butyl-3-ethyl-2,3,4,5-tetrahydro-8-methoxy-5-phenyl-1,4-benzothiazepin-7-ol1,1-dioxide;(3R,5R)-3-Butyl-3-ethyl-2,3,4,5-tetrahydro-7-methoxy-5-phenyl-1,4-benzothiazepin-8-ol1,1-dioxide;(±)-Trans-3-butyl-3-ethyl-2,3,4,5-tetrahydro-8-methoxy-5-phenyl-1,4-benzothiazepine1,1-dioxide;(±)-Trans-3-butyl-3-ethyl-2,3,4,5-tetrahydro-5-phenyl-1,4-benzothiazepin-8-ol1,1-dioxide;(±)-Trans-3-butyl-3-ethyl-2,3,4,5-tetrahydro-5-phenyl-1,4-benzothiazepine-4,8-diol;(±)-Trans-3-butyl-3-ethyl-2,3,4,5-tetrahydro-5-phenyl-1,4-benzothiazepin-8-thiol1,1-dioxide;(±)-Trans-3-butyl-3-ethyl-2,3,4,5-tetrahydro-5-phenyl-1,4-benzothiazepin-8-sulfonicacid 1,1-dioxide;(±)-Trans-3-butyl-3-ethyl-2,3,4,5-tetrahydro-8,9-dimethoxy-5-phenyl-1,4-benzothiazepine1, 1-dioxide;(3R,5R)-3-butyl-7,8-diethoxy-2,3,4,5-tetrahydro-5-phenyl-1,4-benzothiazepine1,1-dioxide;(±)-Trans-3-butyl-8-ethoxy-3-ethyl-2,3,4,5-tetrahydro-5-phenyl-1,4-benzothiazepine1,1-dioxide;(±)-Trans-3-butyl-3-ethyl-2,3,4,5-tetrahydro-8-isopropoxy-5-phenyl-1,4-benzothiazepine1,1-dioxide hydrochloride;(±)-Trans-3-butyl-3-ethyl-2,3,4,5-tetrahydro-5-phenyl-1,4-benzothiazepin-8-carbaldehyde-1,1-dioxide;3,3-Diethyl-2,3,4,5-tetrahydro-7,8-dimethoxy-5-phenyl-1,4-benzothiazepine1,1-dioxide;3,3-Diethyl-2,3,4,5-tetrahydro-8-methoxy-5-phenyl-1,4-benzothiazepine1,1-dioxide;3,3-Diethyl-2,3,4,5-tetrahydro-5-phenyl-1,4-benzothiazpin-4,8-diol1,1-dioxide;(RS)-3,3-Diethyl-2,3,4,5-tetrahydro-4-hydroxy-7,8-dimethoxy-5-phenyl-1,4-benzothiazepine1,1-dioxide;(±)-Trans-3-butyl-8-ethoxy-3-ethyl-2,3,4,5-tetrahydro-5-phenyl-1,4-benzothiazepin-4-ol-1-dioxide;(±)-Trans-3-butyl-3-ethyl-2,3,4,5-tetrahydro-8-isopropoxy-5-phenyl-1,4-benzothiazepin-4-ol1,1-dioxide;(±)-Trans-3-butyl-3-ethyl-2,3,4,5-tetrahydro-7,8,9-trimethoxy-5-phenyl-1,4-benzothiazepin-4-ol1,1-dioxide;(3R,5R)-3-butyl-3-ethyl-2,3,4,5-tetrahydro-5-phenyl-1,4-benzothiazepin-4,7,8-triol1,1-dioxide;(±)-Trans-3-butyl-3-ethyl-2,3,4,5-tetrahydro-4,7,8-trimethoxy-5-phenyl-1,4-benzothiazepine1,1-dioxide;3,3-Diethyl-2,3,4,5-tetrahydro-5-phenyl-1,4-benzothiazepin-8-ol1,1-dioxide;3,3-Diethyl-2,3,4,5-tetrahydro-7-methoxy-5-phenyl-1,4-benzothiazepin-8-ol1,1-dioxide;3,3Dibutyl-2,3,4,5-tetrahydro-5-phenyl-1,4-benzothiazepin-8-ol1,1-dioxide;(±)-Trans-3-Butyl-3-ethyl-2,3,4,5-tetrahydro-1,1-dioxo-5-phenyl-1,4-benzothiazepin-8-ylhydrogen sulfate; or3,3-Diethyl-2,3,4,5-tetrahydro-1,1-dioxo-5-phenyl-1,4-benzothiazepin-8-ylhydrogen sulfate.

In some embodiments, the compound of Formula I is

In some embodiments of the methods, the compound of Formula I is

In some embodiments, the compound of Formula I is not a structure shownas:

wherein m represents an integer of 1 or 2, and R³ and R⁴, which may bemutually different, each represents an alkyl group having 1 to 5 carbonatoms.

In some embodiments, an ASBTI suitable for the methods described hereinis a compound of Formula II

wherein:

q is an integer from 1 to 4;

n is an integer from 0 to 2;

R¹ and R² are independently selected from the group consisting of H,alkyl, alkenyl, alkynyl, haloalkyl, alkylaryl, arylalkyl, alkoxy,alkoxyalkyl, dialkylamino, alkylthio, (polyalkyl)aryl, and cycloalkyl,

wherein alkyl, alkenyl, alkynyl, haloalkyl, alkylaryl, arylalkyl,alkoxy, alkoxyalkyl, dialkylamino, alkylthio, (polyalkyl)aryl, andcycloalkyl optionally are substituted with one or more substituentsselected from the group consisting of OR⁹, NR⁹R¹⁰, N⁺R⁹R¹⁰R^(w)A⁻, SR⁹,S⁺R⁹R¹⁰A⁻, P⁺R⁹R¹⁰R¹¹A⁻, S(O)R⁹, SO₂R⁹, SO₃R⁹, CO₂R⁹, CN, halogen, oxo,and CONR⁹R¹⁰,

wherein alkyl, alkenyl, alkynyl, alkylaryl, alkoxy, alkoxyalkyl,(polyalkyl)aryl, and cycloalkyl optionally have one or more carbonsreplaced by O, NR⁹, N⁺R⁹R¹⁰A⁻, S, SO, SO₂, S⁺R⁹A⁻, P⁺R⁹R¹⁰ A⁻, orphenylene,

wherein R⁹, R¹⁰, and R^(w) are independently selected from the groupconsisting of H, alkyl, alkenyl, alkynyl, cycloalkyl, aryl, acyl,heterocycle, ammoniumalkyl, arylalkyl, and alkylammoniumalkyl; or

R¹ and R² taken together with the carbon to which they are attached formC₃-C₁₀ cycloalkyl;

R³ and R⁴ are independently selected from the group consisting of H,alkyl, alkenyl, alkynyl, acyloxy, aryl, heterocycle, OR⁹, NR⁹R¹⁰, SR⁹,S(O)R⁹, SO₂R⁹, and SO₃R⁹, wherein R⁹ and R¹⁰ are as defined above; or

R³ and R⁴ together ═O, ═NOR₁₁, ═S, ═NNR¹¹R¹², ═NR⁹, or ═CR₁₁R¹²

wherein R¹¹ and R¹² are independently selected from the group consistingof H, alkyl, alkenyl, alkynyl, aryl, arylalkyl, alkenylalkyl,alkynylalkyl, heterocycle, carboxyalkyl, carboalkoxyalkyl, cycloalkyl,cyanoalkyl, OR⁹, NR⁹R¹⁰, SR⁹, S(O)R⁹, SO₂R⁹, SO₃R⁹, CO₂R⁹, CN, halogen,oxo, and CONR⁹R¹⁰, wherein R⁹ and R¹⁰ are as defined above, providedthat both R³ and R⁴ cannot be OH, NH₂, and SH, or

R¹¹ and R¹² together with the nitrogen or carbon atom to which they areattached form a cyclic ring;

R⁵ and R⁶ are independently selected from the group consisting of H,alkyl, alkenyl, alkynyl, aryl, cycloalkyl, heterocycle, quaternaryheterocycle, quarternary heteroaryl, OR⁹, SR⁹, S(O)R⁹, SO₂R⁹, SO₃R⁹, and-L_(z)-K_(z);

wherein z is 1, 2 or 3; each L is independently a substituted orunsubstituted alkyl, a substituted or unsubstituted heteroalkyl, asubstituted or unsubstituted alkoxy, a substituted or unsubstitutedaminoalkyl group, a substituted or unsubstituted aryl, a substituted orunsubstituted heteroaryl, a substituted or unsubstituted cycloalkyl, ora substituted or unsubstituted heterocycloalkyl; each K is a moiety thatprevents systemic absorption;

wherein alkyl, alkenyl, alkynyl, aryl, cycloalkyl, heterocycle,quaternary heterocycle, and quaternary heteroaryl can be substitutedwith one or more substituent groups independently selected from thegroup consisting of alkyl, alkenyl, alkynyl, polyalkyl, polyether, aryl,haloalkyl, cycloalkyl, heterocycle, arylalkyl, quaternary heterocycle,quaternary heteroaryl, halogen, oxo, R¹⁵, OR¹³, OR¹³R¹⁴, NR¹³R¹⁴, SR¹³,S(O)R¹³, SO₂R¹³, SO₃R¹³, NR¹³OR¹⁴, NR¹³NR¹⁴R¹⁵, NO₂, CO₂R¹³, CN, OM,SO₂OM, SO₂NR¹³R¹⁴, C(O)NR¹³R¹⁴, C(O)OM, CR¹³, P(O)R¹³R¹⁴, P⁺R¹³R¹⁴R¹⁵A⁻,P(OR¹³)OR¹⁴, S⁺R¹³R¹⁴A⁻, and N⁺R⁹R¹¹R¹²A⁻,

wherein:

A⁻ is a pharmaceutically acceptable anion and M is a pharmaceuticallyacceptable cation, said alkyl, alkenyl, alkynyl, polyalkyl, polyether,aryl, haloalkyl, cycloalkyl, and heterocycle can be further substitutedwith one or more substituent groups selected from the group consistingof OR⁷, NR⁷R⁸, S(O)R⁷, SO₂R⁷, SO₃R⁷, CO₂R⁷, CN, oxo, CONR⁷R⁸,N⁺R⁷R⁸R⁹A⁻, alkyl, alkenyl, alkynyl, aryl, cycloalkyl, heterocycle,arylalkyl, quaternary heterocycle, quaternary heteroaryl, P(O)R⁷R⁸,P⁺R⁷R⁸R⁹A⁻, and P(O)(OR⁷) OR⁸ and

wherein said alkyl, alkenyl, alkynyl, polyalkyl, polyether, aryl,haloalkyl, cycloalkyl, and heterocycle can optionally have one or morecarbons replaced by O, NR⁷, N⁺R⁷R₈A⁻, S, SO, SO₂, S⁺R⁷A⁻, PR⁷, P(O)R⁷,P⁺R⁷R⁸A⁻, or phenylene, and R¹³, R¹⁴, and R¹⁵ are independently selectedfrom the group consisting of hydrogen, alkyl, alkenyl, alkynyl,polyalkyl, aryl, arylalkyl, cycloalkyl, heterocycle, heteroaryl,quaternary heterocycle, quaternary heteroaryl, quaternaryheteroarylalkyl, and -G-T-V-W,

wherein alkyl, alkenyl, alkynyl, arylalkyl, heterocycle, and polyalkyloptionally have one or more carbons replaced by O, NR⁹, N⁺R⁹R¹⁰A⁻, S,SO, SO₂, S⁺R⁹A⁻, PR, P⁺R⁹R¹⁰A⁻, P(O)R⁹, phenylene, carbohydrate, C₂-C₇polyol, amino acid, peptide, or polypeptide, and

G, T and V are each independently a bond, —O—, —S—, —N(H)—, substitutedor unsubstituted alkyl, —O-alkyl, —N(H)-alkyl, —C(O)N(H)—, —N(H)C(O)—,—N(H)C(O)N(H)—, substituted or unsubstituted alkenyl, substituted orunsubstituted alkynyl, substituted or unsubstituted aryl, substituted orunsubstituted arylalkyl, substituted or unsubstituted alkenylalkyl,alkynylalkyl, substituted or unsubstituted heteroalkyl, substituted orunsubstituted heterocycle, substituted or unsubstituted carboxyalkyl,substituted or unsubstituted carboalkoxyalkyl, or substituted orunsubstituted cycloalkyl, and

W is quaternary heterocycle, quaternary heteroaryl, quaternaryheteroarylalkyl, N⁺R⁹R¹¹R¹²A⁻, P⁺R⁹R¹⁰R¹¹A⁻, OS(O)₂OM, or S⁺R⁹R¹⁰A⁻, and

R¹³, R¹⁴ and R¹⁵ are optionally substituted with one or more groupsselected from the group consisting of sulfoalkyl, quaternaryheterocycle, quaternary heteroaryl, OR⁹, NR⁹R¹⁰, N⁺R⁹R¹¹R¹²A⁻, SR⁹, S(O)R⁹, SO₂R⁹, SO₃R⁹, oxo, CO₂R⁹, CN, halogen, CONR⁹R¹⁰, SO₂OM, SO₂NR⁹R¹⁰,PO(OR¹⁶)OR¹⁷, P⁺R⁹R¹⁰R¹¹A⁻, S⁺R⁹R¹⁰A⁻, and C(O)OM,

wherein R¹⁶ and R¹⁷ are independently selected from the substituentsconstituting R⁹ and M; or

R¹⁴ and R¹⁵, together with the nitrogen atom to which they are attached,form a cyclic ring; and

is selected from the group consisting of alkyl, alkenyl, alkynyl,cycloalkyl, aryl, acyl, heterocycle, ammoniumalkyl, alkylammoniumalkyl,and arylalkyl; and

R⁷ and R⁸ are independently selected from the group consisting ofhydrogen and alkyl; and

one or more R are independently selected from the group consisting of H,alkyl, alkenyl, alkynyl, polyalkyl, acyloxy, aryl, arylalkyl, halogen,haloalkyl, cycloalkyl, heterocycle, heteroaryl, polyether, quaternaryheterocycle, quaternary heteroaryl, OR¹³, NR¹³R¹⁴, SR¹³, S(O)R¹³,S(O)₂R¹³, SO₃R¹³, S⁺R¹³R¹⁴A⁻, NR¹³OR¹⁴, NR¹³NR¹⁴R¹⁵, NO₂, CO₂R¹³, CN,OM, SO₂OM, SO₂NR¹³R¹⁴, NR¹⁴C(O)R¹³, C(O)NR¹³R¹⁴, NR¹⁴C(O)R¹³, C(O)OM,COR¹³, OR¹⁸, S(O)_(n) NR¹⁸, NR¹³R¹⁸, NR¹⁸R¹⁴, N⁺R⁹R¹¹R¹²A⁻,P⁺R⁹R¹¹R¹²A⁻, amino acid, peptide, polypeptide, and carbohydrate,

wherein alkyl, alkenyl, alkynyl, cycloalkyl, aryl, polyalkyl,heterocycle, acyloxy, arylalkyl, haloalkyl, polyether, quaternaryheterocycle, and quaternary heteroaryl can be further substituted withOR⁹, NR⁹R¹⁰, N⁺R⁹R¹¹R¹²A⁻, SR⁹, S(O)R⁹, SO₂R⁹, SO₃R⁹, oxo, CO₂R⁹, CN,halogen, CONR⁹R¹⁰, SO₂OM, SO₂NR⁹R¹⁰, PO(OR¹⁶)OR¹⁷, P⁺R⁹R¹¹R¹²A⁻,S⁺R⁹R¹⁰A⁻, or C(O)M, and

wherein R¹⁸ is selected from the group consisting of acyl,arylalkoxycarbonyl, arylalkyl, heterocycle, heteroaryl, alkyl,

wherein acyl, arylalkoxycarbonyl, arylalkyl, heterocycle, heteroaryl,alkyl, quaternary heterocycle, and quaternary heteroaryl optionally aresubstituted with one or more substituents selected from the groupconsisting of OR⁹, NR⁹R¹⁰, N⁺R⁹R¹¹R¹²A⁻, SR⁹, S(O)R⁹, SO₂R⁹, SO₃R⁹, oxo,CO₃R⁹, CN, halogen, CONR⁹R¹⁰, SO₃R⁹, SO₂OM, SO₂NR⁹R¹⁰, PO(OR¹⁶)OR¹⁷, andC(O)OM,

wherein in R^(x), one or more carbons are optionally replaced by O,NR¹³, N⁺R¹³R¹⁴A⁻, S, SO, SO₂, S⁺R¹³A⁻, PR¹³, P(O)R¹³, P⁺R¹³R¹⁴A⁻,phenylene, amino acid, peptide, polypeptide, carbohydrate, polyether, orpolyalkyl,

wherein in said polyalkyl, phenylene, amino acid, peptide, polypeptide,and carbohydrate, one or more carbons are optionally replaced by O, NR⁹,R⁹R¹⁰A⁻, S, SO, SO₂, S⁺R⁹A⁻, PR⁹, P⁺R⁹R¹⁰A⁻, or P(O)R⁹;

wherein quaternary heterocycle and quaternary heteroaryl are optionallysubstituted with one or more groups selected from the group consistingof alkyl, alkenyl, alkynyl, polyalkyl, polyether, aryl, haloalkyl,cycloalkyl, heterocycle, arylalkyl, halogen, oxo, OR¹³, NR¹³R¹⁴, SR¹³,S(O)R¹³, SO₂R¹³, SO₃R¹³, NR¹³OR¹⁴, NR¹³NR¹⁴R¹⁵, NO₂, CO₂R¹³, CN, OM,SO₂OM, SO₂NR¹³R¹⁴, C(O)NR¹³R¹⁴, C(O)OM, COR¹³, P(O)R¹³R¹⁴,P⁺R¹³R¹⁴R¹⁵A⁻, P(OR¹³)OR¹⁴, S⁺R¹³R¹⁴A⁻, and N⁺R⁹R¹¹R¹²A⁻,

provided that both R⁵ and R⁶ cannot be hydrogen or SH;

provided that when R⁵ or R⁶ is phenyl, only one of R¹ or R² is H;

provided that when q=1 and R^(x) is styryl, anilido, or anilinocarbonyl,only one of R⁵ or R⁶ is alkyl; or a pharmaceutically acceptable salt,solvate, or prodrug thereof.

In some embodiments of the methods, the compound of Formula II is acompound wherein

q is an integer from 1 to 4;

n is 2;

R¹ and R² are independently selected from the group consisting of H,alkyl, alkoxy, dialkylamino, and alkylthio,

wherein alkyl, alkoxy, dialkylamino, and alkylthio are optionallysubstituted with one or more substituents selected from the groupconsisting of OR⁹, NR⁹R¹⁰, SR⁹, SO₂R⁹, CO₂R⁹, CN, halogen, oxo, andCONR⁹R¹⁰;

each R⁹ and R¹⁰ are each independently selected from the groupconsisting of H, alkyl, cycloalkyl, aryl, acyl, heterocycle, andarylalkyl;

R³ and R⁴ are independently selected from the group consisting of H,alkyl, acyloxy, OR⁹, NR⁹R¹⁰, SR⁹, and SO₂R⁹, wherein R⁹ and R¹⁰ are asdefined above;

R¹¹ and R¹² are independently selected from the group consisting of H,alkyl, alkenyl, alkynyl, aryl, arylalkyl, alkenylalkyl, alkynylalkyl,heterocycle, carboxyalkyl, carboalkoxyalkyl, cycloalkyl, cyanoalkyl,OR⁹, NR⁹R¹⁰, SR⁹, S(O)R⁹, SO₂R⁹, SO₃R⁹, CO₂R⁹, CN, halogen, oxo, andCONR⁹R¹⁰, wherein R⁹ and R¹⁰ are as defined above, provided that both R³and R⁴ cannot be OH, NH₂, and SH, or

R¹¹ and R¹² together with the nitrogen or carbon atom to which they areattached form a cyclic ring;

R⁵ and R⁶ are independently selected from the group consisting of H,alkyl, aryl, cycloalkyl, heterocycle, and -L_(z)-K_(z);

wherein z is 1 or 2; each L is independently a substituted orunsubstituted alkyl, a substituted or unsubstituted heteroalkyl, asubstituted or unsubstituted aryl, a substituted or unsubstitutedheteroaryl, a substituted or unsubstituted cycloalkyl, or a substitutedor unsubstituted heterocycloalkyl; each K is a moiety that preventssystemic absorption;

wherein alkyl, aryl, cycloalkyl, and heterocycle can be substituted withone or more substituent groups independently selected from the groupconsisting of alkyl, aryl, haloalkyl, cycloalkyl, heterocycle,arylalkyl, quaternary heterocycle, quaternary heteroaryl, halogen, oxo,OR¹³, OR¹³R¹⁴, NR¹³R¹⁴, SR¹³, SO₂R¹³, NR¹³NR¹⁴R¹⁵, NO₂, CO₂R¹³, CN, OM,and CR¹³,

wherein:

A⁻ is a pharmaceutically acceptable anion and M is a pharmaceuticallyacceptable cation;

R¹³, R¹⁴, and R¹⁵ are independently selected from the group consistingof hydrogen, alkyl, alkenyl, alkynyl, polyalkyl, aryl, arylalkyl,cycloalkyl, heterocycle, heteroaryl, quaternary heterocycle, quaternaryheteroaryl, and quaternary heteroarylalkyl, wherein R¹³, R¹⁴ and R¹⁵ areoptionally substituted with one or more groups selected from the groupconsisting of quaternary heterocycle, quaternary heteroaryl, OR⁹,NR⁹R¹⁰, N⁺R⁹R¹¹R¹²A⁻, SR⁹, S(O) R⁹, SO₂R⁹, SO₃R⁹, oxo, CO₂R⁹, CN,halogen, and CONR⁹R¹⁰; or

R¹⁴ and R¹⁵, together with the nitrogen atom to which they are attached,form a cyclic ring; and

is selected from the group consisting of alkyl, alkenyl, alkynyl,cycloalkyl, aryl, acyl, heterocycle, ammoniumalkyl, alkylammoniumalkyl,and arylalkyl; and

R⁷ and R⁸ are independently selected from the group consisting ofhydrogen and alkyl; and

one or more R^(x) are independently selected from the group consistingof H, alkyl, acyloxy, aryl, arylalkyl, halogen, haloalkyl, cycloalkyl,heterocycle, heteroaryl, OR¹³, NR¹³R¹⁴, SR¹³, S(O)₂R¹³, NR¹³NR¹⁴R¹⁵,NO₂, CO₂R¹³, CN, SO₂NR¹³R¹⁴, NR¹⁴C(O)R¹³, C(O)NR¹³R¹⁴, NR¹⁴C(O)R¹³, andCOR¹³;

provided that both R⁵ and R⁶ cannot be hydrogen;

provided that when R⁵ or R⁶ is phenyl, only one of R¹ or R² is H;

provided that when q=1 and R^(x) is styryl, anilido, or anilinocarbonyl,only one of R⁵ or R⁶ is alkyl; or a pharmaceutically acceptable salt,solvate, or prodrug thereof.

In some embodiments, the compound of Formula II is a compound wherein

q is 1;

n is 2;

R^(x) is N(CH₃)₂;

R⁷ and R⁸ are independently H;

R¹ and R² is alkyl;

R³ is H, and R⁴ is OH;

R⁵ is H, and R⁶ is selected from the group consisting of alkyl, alkenyl,alkynyl, aryl, cycloalkyl, heterocycle, quaternary heterocycle,quarternary heteroaryl, OR⁹, SR⁹, S(O)R⁹, SO₂R⁹, SO₃R⁹, and-L_(z)-K_(z);

wherein z is 1, 2 or 3; each L is independently a substituted orunsubstituted alkyl, a substituted or unsubstituted heteroalkyl, asubstituted or unsubstituted alkoxy, a substituted or unsubstitutedaminoalkyl group, a substituted or unsubstituted aryl, a substituted orunsubstituted heteroaryl, a substituted or unsubstituted cycloalkyl, ora substituted or unsubstituted heterocycloalkyl; each K is a moiety thatprevents systemic absorption;

wherein alkyl, alkenyl, alkynyl, aryl, cycloalkyl, heterocycle,quaternary heterocycle, and quaternary heteroaryl can be substitutedwith one or more substituent groups independently selected from thegroup consisting of alkyl, alkenyl, alkynyl, polyalkyl, polyether, aryl,haloalkyl, cycloalkyl, heterocycle, arylalkyl, quaternary heterocycle,quaternary heteroaryl, halogen, oxo, R¹⁵, OR¹³, OR¹³R¹⁴, NR¹³R¹⁴, SR¹³,S(O)R¹³, SO₂R¹³, SO₃R¹³, NR¹³OR¹⁴, NR¹³NR¹⁴R¹⁵, NO₂, CO₂R¹³, CN, OM,SO₂OM, SO₂NR¹³R¹⁴, C(O)NR¹³R¹⁴, C(O)OM, CR¹³, P(O)R¹³R¹⁴, P⁺R¹³R¹⁴R¹⁵A⁻,P(OR¹³)OR¹⁴, S⁺R¹³R¹⁴A⁻, and N⁺R⁹R¹¹R¹²A⁻,

wherein A⁻ is a pharmaceutically acceptable anion and M is apharmaceutically acceptable cation, said alkyl, alkenyl, alkynyl,polyalkyl, polyether, aryl, haloalkyl, cycloalkyl, and heterocycle canbe further substituted with one or more substituent groups selected fromthe group consisting of OR⁷, NR⁷R⁸, S(O)R⁷, SO₂R⁷, SO₃R⁷, CO₂R⁷, CN,oxo, CONR⁷R⁸, N⁺R⁷R⁸R⁹A⁻, alkyl, alkenyl, alkynyl, aryl, cycloalkyl,heterocycle, arylalkyl, quaternary heterocycle, quaternary heteroaryl,P(O)R⁷R⁸, P⁺R⁷R⁸R⁹A⁻, and P(O)(OR⁷) OR₈ and

wherein said alkyl, alkenyl, alkynyl, polyalkyl, polyether, aryl,haloalkyl, cycloalkyl, and heterocycle can optionally have one or morecarbons replaced by O, NR⁷, N⁺R⁷R₈A⁻, S, SO, SO₂, S⁺R⁷A⁻, PR⁷, P(O)R⁷,P⁺R⁷R⁸A⁻, or phenylene, and R¹³, R¹⁴, and R¹⁵ are independently selectedfrom the group consisting of hydrogen, alkyl, alkenyl, alkynyl,polyalkyl, aryl, arylalkyl, cycloalkyl, heterocycle, heteroaryl,quaternary heterocycle, quaternary heteroaryl, quaternaryheteroarylalkyl, and -G-T-V-W,

wherein alkyl, alkenyl, alkynyl, arylalkyl, heterocycle, and polyalkyloptionally have one or more carbons replaced by O, NR⁹, N⁺R⁹R¹⁰A⁻, S,SO, SO₂, S⁺R⁹A⁻, PR, P⁺R⁹R¹⁰A⁻, P(O)R⁹, phenylene, carbohydrate, C₂-C₇polyol, amino acid, peptide, or polypeptide, and

G, T and V are each independently a bond, —O—, —S—, —N(H)—, substitutedor unsubstituted alkyl, —O-alkyl, —N(H)-alkyl, —C(O)N(H)—, —N(H)C(O)—,—N(H)C(O)N(H)—, substituted or unsubstituted alkenyl, substituted orunsubstituted alkynyl, substituted or unsubstituted aryl, substituted orunsubstituted arylalkyl, substituted or unsubstituted alkenylalkyl,alkynylalkyl, substituted or unsubstituted heteroalkyl, substituted orunsubstituted heterocycle, substituted or unsubstituted carboxyalkyl,substituted or unsubstituted carboalkoxyalkyl, or substituted orunsubstituted cycloalkyl, and

W is quaternary heterocycle, quaternary heteroaryl, quaternaryheteroarylalkyl, N⁺R⁹R¹¹R¹²A⁻, P⁺R⁹R¹⁰R¹¹A⁻, OS(O)₂OM, or S⁺R⁹R₁₀A⁻, and

R⁹ and R¹⁰ are independently selected from the group consisting of H,alkyl, alkenyl, alkynyl, cycloalkyl, aryl, acyl, heterocycle,ammoniumalkyl, arylalkyl, and alkylammoniumalkyl;

R¹¹ and R¹² are independently selected from the group consisting of H,alkyl, alkenyl, alkynyl, aryl, arylalkyl, alkenylalkyl, alkynylalkyl,heterocycle, carboxyalkyl, carboalkoxyalkyl, cycloalkyl, cyanoalkyl,OR⁹, NR⁹R¹⁰, SR⁹, S(O)R⁹, SO₂R⁹, SO₃R⁹, CO₂R⁹, CN, halogen, oxo, andCONR⁹R¹⁰, wherein R⁹ and R¹⁰ are as defined above, provided that both R³and R⁴ cannot be OH, NH₂, and SH, or

R¹¹ and R¹² together with the nitrogen or carbon atom to which they areattached form a cyclic ring;

R¹³, R¹⁴ and R¹⁵ are optionally substituted with one or more groupsselected from the group consisting of sulfoalkyl, quaternaryheterocycle, quaternary heteroaryl, OR⁹, NR⁹R¹⁰, N⁺R⁹R¹¹R¹²A⁻, SR⁹, S(O)R⁹, SO₂R⁹, SO₃R⁹, oxo, CO₂R⁹, CN, halogen, CONR⁹R¹⁰, SO₂OM, SO₂NR⁹R¹⁰,PO(OR¹⁶)OR¹⁷, P⁺R⁹R¹⁰R¹¹A⁻, S⁺R⁹R¹⁰A⁻, and C(O)OM,

wherein R¹⁶ and R¹⁷ are independently selected from the substituentsconstituting R⁹ and M; or

R¹⁴ and R¹⁵, together with the nitrogen atom to which they are attached,form a cyclic ring; and is selected from the group consisting of alkyl,alkenyl, alkynyl, cycloalkyl, aryl, acyl, heterocycle, ammoniumalkyl,alkylammoniumalkyl, and arylalkyl;

or a pharmaceutically acceptable salt, solvate, or prodrug thereof.

In some embodiments, the compound of Formula II is a compound wherein

q is 1;

n is 2;

R is N(CH₃)₂;

R⁷ and R⁸ are independently H;

R¹ and R² is independently C₁-C₄ alkyl;

R³ is H, and R⁴ is OH;

R⁵ is H, and R⁶ is arylsubstituted with one or more substituent groupsindependently selected from the group consisting of alkyl, alkenyl,alkynyl, polyalkyl, polyether, aryl, haloalkyl, cycloalkyl, heterocycle,arylalkyl, quaternary heterocycle, quaternary heteroaryl, halogen, oxo,R¹⁵, OR¹³, OR¹³R¹⁴, NR¹³R¹⁴, SR¹³, S(O)R¹³, SO₂R¹³, SO₃R¹³, NR¹³OR¹⁴,NR¹³NR¹⁴R¹⁵, NO₂, CO₂R¹³, CN, OM, SO₂OM, SO₂NR¹³R¹⁴, C(O)NR¹³R¹⁴,C(O)OM, CR¹³, P(O)R¹³R¹⁴, P⁺R¹³R¹⁴R¹⁵A⁻, P(OR¹³)OR¹⁴, S⁺R¹³R¹⁴A⁻, andN⁺R⁹R¹¹R¹²A

wherein A⁻ is a pharmaceutically acceptable anion and M is apharmaceutically acceptable cation, said alkyl, alkenyl, alkynyl,polyalkyl, polyether, aryl, haloalkyl, cycloalkyl, and heterocycle canbe further substituted with one or more substituent groups selected fromthe group consisting of OR⁷, NR⁷R⁸, S(O)R⁷, SO₂R⁷, SO₃R⁷, CO₂R⁷, CN,oxo, CONR⁷R⁸, N⁺R⁷R⁸R⁹A⁻, alkyl, alkenyl, alkynyl, aryl, cycloalkyl,heterocycle, arylalkyl, quaternary heterocycle, quaternary heteroaryl,P(O)R⁷R⁸, P⁺R⁷R⁸R⁹A⁻, and P(O)(OR⁷) OR₈ and

wherein said alkyl, alkenyl, alkynyl, polyalkyl, polyether, aryl,haloalkyl, cycloalkyl, and heterocycle can optionally have one or morecarbons replaced by O, NR⁷, N⁺R⁷R₈A⁻, S, SO, SO₂, S⁺R⁷A⁻, PR⁷, P(O)R⁷,P⁺R⁷R⁸A⁻, or phenylene, and R¹³, R¹⁴, and R¹⁵ are independently selectedfrom the group consisting of hydrogen, alkyl, alkenyl, alkynyl,polyalkyl, aryl, arylalkyl, cycloalkyl, heterocycle, heteroaryl,quaternary heterocycle, quaternary heteroaryl, quaternaryheteroarylalkyl, and -G-T-V-W,

wherein alkyl, alkenyl, alkynyl, arylalkyl, heterocycle, and polyalkyloptionally have one or more carbons replaced by O, NR⁹, N⁺R⁹R¹⁰A⁻, S,SO, SO₂, S⁺R⁹A⁻, PR, P⁺R⁹R¹⁰A⁻, P(O)R⁹, phenylene, carbohydrate, C₂-C₇polyol, amino acid, peptide, or polypeptide, and

G, T and V are each independently a bond, —O—, —S—, —N(H)—, substitutedor unsubstituted alkyl, —O-alkyl, —N(H)-alkyl, —C(O)N(H)—, —N(H)C(O)—,—N(H)C(O)N(H)—, substituted or unsubstituted alkenyl, substituted orunsubstituted alkynyl, substituted or unsubstituted aryl, substituted orunsubstituted arylalkyl, substituted or unsubstituted alkenylalkyl,alkynylalkyl, substituted or unsubstituted heteroalkyl, substituted orunsubstituted heterocycle, substituted or unsubstituted carboxyalkyl,substituted or unsubstituted carboalkoxyalkyl, or substituted orunsubstituted cycloalkyl, and

W is quaternary heterocycle, quaternary heteroaryl, quaternaryheteroarylalkyl, N⁺R⁹R¹¹R¹²A⁻, P⁺R⁹R¹R¹¹A⁻, OS(O)₂OM, or S⁺R⁹R¹⁰A⁻, and

R⁹ and R¹⁰ are independently selected from the group consisting of H,alkyl, alkenyl, alkynyl, cycloalkyl, aryl, acyl, heterocycle,ammoniumalkyl, arylalkyl, and alkylammoniumalkyl;

R¹¹ and R¹² are independently selected from the group consisting of H,alkyl, alkenyl, alkynyl, aryl, arylalkyl, alkenylalkyl, alkynylalkyl,heterocycle, carboxyalkyl, carboalkoxyalkyl, cycloalkyl, cyanoalkyl,OR⁹, NR⁹R¹⁰, SR⁹, S(O)R⁹, SO₂R⁹, SO₃R⁹, CO₂R⁹, CN, halogen, oxo, andCONR⁹R¹⁰, wherein R⁹ and R¹⁰ are as defined above, provided that both R³and R⁴ cannot be OH, NH₂, and SH, or

R¹¹ and R¹² together with the nitrogen or carbon atom to which they areattached form a cyclic ring;

R¹³, R¹⁴ and R¹⁵ are optionally substituted with one or more groupsselected from the group consisting of sulfoalkyl, quaternaryheterocycle, quaternary heteroaryl, OR⁹, NR⁹R¹⁰, N⁺R⁹R¹¹R¹²A⁻, SR⁹, S(O)R⁹, SO₂R⁹, SO₃R⁹, oxo, CO₂R⁹, CN, halogen, CONR⁹R¹⁰, SO₂OM, SO₂NR⁹R¹⁰,PO(OR¹⁶)OR¹⁷, P⁺R⁹R¹⁰R¹¹A⁻, S⁺R⁹R¹⁰A⁻, and C(O)OM,

wherein R¹⁶ and R¹⁷ are independently selected from the substituentsconstituting R⁹ and M; or

R¹⁴ and R¹⁵, together with the nitrogen atom to which they are attached,form a cyclic ring; and is selected from the group consisting of alkyl,alkenyl, alkynyl, cycloalkyl, aryl, acyl, heterocycle, ammoniumalkyl,alkylammoniumalkyl, and arylalkyl;

or a pharmaceutically acceptable salt, solvate, or prodrug thereof.

In some embodiments of the methods, the compound of Formula II is acompound

wherein

R⁵ and R⁶ are independently selected from the group consisting of H,aryl, heterocycle, quaternary heterocycle, and quarternary heteroaryl

wherein the aryl, heteroaryl, quaternary heterocycle and quaternaryheteroaryl are optionally substituted with one or more groups selectedfrom the group consisting of alkyl, alkenyl, alkynyl, polyalkyl,polyether, aryl, haloalkyl, cycloalkyl, heterocycle, arylalkyl, halogen,oxo, OR¹³, OR¹³R¹⁴, NR¹³R¹⁴, SR¹³, S(O)R¹³, SO₂R¹³, SO₃R¹³, NR¹³OR¹⁴,NR¹³NR¹⁴R¹⁵, NO₂, CO₂R¹³, CN, OM, SO₂OM, SO₂NR¹³R¹⁴, C(O)NR¹³R¹⁴,C(O)OM, COR¹³, P(O)R¹³R¹⁴, P⁺R¹³R¹⁴R¹⁵A⁻, P(OR¹³)OR¹⁴, S⁺R¹³R¹⁴A⁻,N⁺R⁹R¹¹R¹²A⁻ and -L_(z)-K_(z).

In some embodiments of the methods, the compound of Formula II is acompound

wherein

R⁵ or R⁶ is —Ar—(R^(y))_(t)

t is an integer from 0 to 5;

Ar is selected from the group consisting of phenyl, thiophenyl, pyridyl,piperazinyl, piperonyl, pyrrolyl, naphthyl, furanyl, anthracenyl,quinolinyl, isoquinolinyl, quinoxalinyl, imidazolyl, pyrazolyl,oxazolyl, isoxazolyl, pyrimidinyl, thiazolyl, triazolyl, isothiazolyl,indolyl, benzoimidazolyl, benzoxazolyl, benzothiazolyl, andbenzoisothiazolyl; and

one or more R^(y) are independently selected from the group consistingof alkyl, alkenyl, alkynyl, polyalkyl, polyether, aryl, halo alkyl,cycloalkyl, heterocycle, arylalkyl, halogen, oxo, OR¹³, OR¹³R¹⁴,NR¹³R¹⁴, SR¹³, S(O)R¹³, SO₂R¹³, SO₃R¹³, NR¹³OR¹⁴, NR¹³NR¹⁴R¹⁵, NO₂,CO₂R¹³, CN, OM, SO₂OM, SO₂NR¹³R¹⁴, C(O)NR¹³R¹⁴, C(O)OM, COR¹³,P(O)R¹³R¹⁴, P⁺R¹³R¹⁴R¹⁵A⁻, P(OR¹³)OR¹⁴, S⁺R¹³R¹⁴A⁻, N⁺R⁹R¹¹R¹²A⁻ and-L_(z)-K_(z);

wherein said alkyl, alkenyl, alkynyl, polyalkyl, polyether, aryl,haloalkyl, cycloalkyl, and heterocycle can be further substituted withone or more substituent groups selected from the group consisting ofOR¹³, NR¹³R¹⁴, SR¹³, S(O)R¹³, SO₂R¹³, SO₃R¹³, NR¹³OR¹⁴, NR¹³NR¹⁴R¹⁵,NO₂, CO₂R¹³, CN, oxo, CONR⁷R⁸, N⁺R⁷R⁸R⁹A⁻, alkyl, alkenyl, alkynyl,aryl, cycloalkyl, heterocycle, arylalkyl, quaternary heterocycle,quaternary heteroaryl, P(O)R⁷R⁸, P⁺R⁷R⁸A⁻, and P(O)(OR⁷)OR⁸, and orphenylene;

wherein said alkyl, alkenyl, alkynyl, polyalkyl, polyether, aryl,haloalkyl, cycloalkyl, and heterocycle can optionally have one or morecarbons replaced by O, NR⁷, N⁺R⁷R⁸A⁻, S, SO, SO₂, S⁺R⁷A⁻, PR⁷, P(O)R⁷,P⁺R⁷R⁸A⁻, or phenylene.

In some embodiments of the methods, the compound of Formula II is acompound wherein

R⁵ or R⁶ is

In some embodiments of the methods, the compound of Formula II is acompound wherein n is 1 or 2. In some embodiments of the methods, thecompound of Formula II is a compound wherein R¹ and R² are independentlyH or C₁₋₇ alkyl. In some embodiments of the methods, the compound ofFormula II is a compound wherein each C₁₋₇ alkyl is independently ethyl,n-propyl, n-butyl, or isobutyl. In some embodiments of the methods, thecompound of Formula II is a compound wherein R³ and R⁴ are independentlyH or OR⁹. In some embodiments of the methods, compound of Formula II isa compound wherein R⁹ is H

In some embodiments of the methods, the compound of Formula II is acompound wherein one or more R^(x) are in the 7-, 8- or 9-position ofthe benzo ring of Formula II. In some embodiments of the methods, thecompound of Formula II is a compound wherein R^(x) is in the 7-positionof the benzo ring of Formula II. In some embodiments of the methods, thecompound of Formula II is a compound wherein one or more R^(x) areindependently selected from OR¹³ and NR¹³R¹⁴.

In some embodiments of the methods, the compound of Formula II is acompound

wherein:

q is 1 or 2;

n is 2;

R¹ and R² are each alkyl;

R³ is hydroxy;

R⁴ and R⁶ are hydrogen;

R⁵ has the formula

wherein

t is an integer from 0 to 5;

one or more R^(γ) are OR¹³ or OR¹³R¹⁴;

R¹³ and R¹⁴ are independently selected from the group consisting ofhydrogen, alkyl, alkenyl, alkynyl, polyalkyl, aryl, arylalkyl,cycloalkyl, heterocycle, heteroaryl, quaternary heterocycle, quaternaryheteroaryl, and quaternary heteroarylalkyl;

wherein said alkyl, alkenyl, alkynyl, arylalkyl, heterocycle, andpolyalkyl groups optionally have one or more carbons replaced by O, NR⁹,N⁺R⁹R¹⁰A⁻, S, SO, SO₂, S⁺R⁹A⁻, PR⁹, P⁺R⁹R¹⁰A⁻, P(O)R⁹, phenylene,carbohydrate, amino acid, peptide, or polypeptide;

R¹³ and R¹⁴ are optionally substituted with one or more groupsindependently selected from the group consisting of sulfoalkyl,quaternary heterocycle, quaternary heteroaryl, OR⁹, NR⁹R¹⁰,N⁺R⁹R¹¹R¹²A⁻, SR⁹, S(O)R⁹, SO₂R⁹, SO₃R⁹, oxo, CO₂R⁹, CN, halogen,CONR⁹R¹⁰, SO₂OM, SO₂NR⁹R¹⁰, PO(OR¹⁶)OR¹⁷, P⁺R⁹R¹⁰R¹¹A⁻, S⁺R⁹R¹⁰A⁻, andC(O)OM,

wherein A is a pharmaceutically acceptable anion, and M is apharmaceutically acceptable cation,

R⁹ and R¹⁰ are independently selected from the group consisting of H,alkyl, alkenyl, alkynyl, cycloalkyl, aryl, acyl, heterocycle,ammoniumalkyl, arylalkyl, and alkylammoniumalkyl;

R¹¹ and R¹² are independently selected from the group consisting of H,alkyl, alkenyl, alkynyl, aryl, arylalkyl, alkenylalkyl, alkynylalkyl,heterocycle, carboxyalkyl, carboalkoxyalkyl, cycloalkyl, cyanoalkyl,OR⁹, NR⁹R¹⁰, SR⁹, S(O)R⁹, SO₂R⁹, SO₃R⁹, CO₂R⁹, CN, halogen, oxo, andCONR⁹R¹⁰, wherein R⁹ and R^(1°) are as defined above, provided that bothR³ and R⁴ cannot be OH, NH₂, and SH; or

R¹¹ and R¹² together with the nitrogen or carbon atom to which they areattached form a cyclic ring; and

R¹⁶ and R¹⁷ are independently selected from the substituentsconstituting R⁹ and M;

R⁷ and R⁸ are hydrogen; and

one or more R are independently selected from the group consisting ofalkoxy, alkylamino and dialkylamino and —W—R³¹, wherein W is O or NH andR³¹ is selected from

or a pharmaceutically acceptable salt, solvate, or prodrug thereof.

In some embodiments, a compound of Formula II is

or the like.

In some embodiments of the methods, the compound of Formula II is

In certain embodiments, ASBTIs suitable for the methods described hereinare non-systemic analogs of Compound 100C. Certain compounds providedherein are Compound 100C analogues modified or substituted to comprise acharged group. In specific embodiments, the Compound 100C analogues aremodified or substituted with a charged group that is an ammonium group(e.g., a cyclic ar acyclic ammonium group). In certain embodiments, theammonium group is a non-protic ammonium group that contains aquarternary nitrogen.

In some embodiments, a compound of Formula II is

In some embodiments, a compound of Formula II is1-[[5-[[3-[(3S,4R,5R)-3-butyl-7-(dimethylamino)-3-ethyl-2,3,4,5-tetrahydro-4-hydroxy-1,1-dioxido-1-benzothiepin-5yl]phenyl]amino]-5-oxopentyl]amino]-1-deoxy-D-glucitolor SA HMR1741 (a.k.a. BARI-1741).

In some embodiments, a compound of Formula II is

In some embodiments, a compound of Formula II ispotassium((2R,3R,4S,5R,6R)-4-benzyloxy-6-{3-[3-((3S,4R,5R)-3-butyl-7-dimethylamino-3-ethyl-4-hydroxy-1,1-dioxo-2,3,4,5-tetrahydro-1H-benzo[b]thiepin-5-yl)-phenyl]-ureido}-3,5-dihydroxy-tetrahydro-pyran-2-ylmethyl)sulphateethanolate, hydrate or SAR548304B (a.k.a. SAR-548304).

In some embodiments, an ASBTI suitable for the methods described hereinis a compound of Formula III:

wherein:

each R¹, R² is independently H, hydroxy, alkyl, alkoxy, —C(═X)YR⁸,—YC(═X)R⁸, substituted or unsubstituted alkyl, substituted orunsubstituted heteroalkyl, substituted or unsubstituted aryl,substituted or unsubstituted alkyl-aryl, substituted or unsubstitutedcycloalkyl, substituted or unsubstituted alkyl-cycloalkyl, substitutedor unsubstituted heteroaryl, substituted or unsubstitutedalkyl-heteroaryl, substituted or unsubstituted heterocycloalkyl,substituted or unsubstituted alkyl-heterocycloalkyl, or -L-K; or R¹ andR² together with the nitrogen to which they are attached form a3-8-membered ring that is optionally substituted with R⁸;

each R³, R⁴ is independently H, hydroxy, alkyl, alkoxy, —C(═X)YR⁸,—YC(═X)R⁸, substituted or unsubstituted alkyl, substituted orunsubstituted heteroalkyl, substituted or unsubstituted aryl,substituted or unsubstituted alkyl-aryl, substituted or unsubstitutedcycloalkyl, substituted or unsubstituted alkyl-cycloalkyl, substitutedor unsubstituted heteroaryl, substituted or unsubstitutedalkyl-heteroaryl, substituted or unsubstituted heterocycloalkyl,substituted or unsubstituted alkyl-heterocycloalkyl, or -L-K;

R⁵ is H, hydroxy, alkyl, alkoxy, —C(═X)YR⁸, —YC(═X)R⁸, substituted orunsubstituted alkyl, substituted or unsubstituted heteroalkyl,substituted or unsubstituted aryl, substituted or unsubstitutedalkyl-aryl, substituted or unsubstituted cycloalkyl, substituted orunsubstituted alkyl-cycloalkyl, substituted or unsubstituted heteroaryl,substituted or unsubstituted alkyl-heteroaryl, substituted orunsubstituted heterocycloalkyl, substituted or unsubstitutedalkyl-heterocycloalkyl,

each R⁶, R⁷ is independently H, hydroxy, alkyl, alkoxy, —C(═X)YR⁸,—YC(═X)R⁸, substituted or unsubstituted alkyl, substituted orunsubstituted heteroalkyl, substituted or unsubstituted aryl,substituted or unsubstituted alkyl-aryl, substituted or unsubstitutedcycloalkyl, substituted or unsubstituted alkyl-cycloalkyl, substitutedor unsubstituted heteroaryl, substituted or unsubstitutedalkyl-heteroaryl, substituted or unsubstituted heterocycloalkyl,substituted or unsubstituted alkyl-heterocycloalkyl, or -L-K; or R⁶ andR⁷ taken together form a bond;

each X is independently NH, S, or O;

each Y is independently NH, S, or O;

R⁸ is substituted or unsubstituted alkyl, substituted or unsubstitutedheteroalkyl, substituted or unsubstituted aryl, substituted orunsubstituted alkyl-aryl, substituted or unsubstituted cycloalkyl,substituted or unsubstituted alkyl-cycloalkyl, substituted orunsubstituted heteroaryl, substituted or unsubstituted alkyl-heteroaryl,substituted or unsubstituted heterocycloalkyl, substituted orunsubstituted alkyl-heterocycloalkyl, or -L-K;

L is A_(m), wherein

each A is independently NR¹, S(O)_(m), O, C(═X)Y, Y(C═X), substituted orunsubstituted alkyl, substituted or unsubstituted heteroalkyl,substituted or unsubstituted aryl, substituted or unsubstitutedheteroaryl, substituted or unsubstituted cycloalkyl, or substituted orunsubstituted heterocycloalkyl; wherein each m is independently 0-2;

n is 0-7;

K is a moiety that prevents systemic absorption;

provided that at least one of R¹, R², R³ or R⁴ is -L-K;

or a pharmaceutically acceptable prodrug thereof.

In some embodiments of a compound of Formula III, R¹ and R³ are -L-K. Insome embodiments, R¹, R² and R³ are -L-K.

In some embodiments, at least one of R¹, R², R³, R⁴, R⁵, R⁶ and R⁷ is H.In certain embodiments, R⁵, R⁶, R⁷ are H and R¹, R², R³ and R⁴ arealkyl, aryl, alkyl-aryl, or heteroalkyl. In some embodiments, R¹ and R²are H. In some embodiments, R¹, R², R⁵, R⁶ and R⁷ are H. In someembodiments, R⁶ and R⁷ together form a bond. In certain embodiments, R⁵,R⁶ and R⁷ are H, alkyl or O-alkyl.

In some embodiments, R¹ and R³ are -L-K. In some embodiments, R¹, R² andR³ are -L-K. In some embodiments, R³ and R⁴ are -L-K. In someembodiments, R¹ and R² together with the nitrogen to which they areattached form a 3-8 membered ring and the ring is substituted with -L-K.In some embodiments, R¹ or R² or R³ or R⁴ are aryl optionallysubstituted with -L-K. In some embodiments, R¹ or R² or R³ or R⁴ arealkyl optionally substituted with -L-K. In some embodiments, R¹ or R² orR³ or R⁴ are alky-aryl optionally substituted with -L-K. In someembodiments, R¹ or R² or R³ or R⁴ are heteroalkyl optionally substitutedwith -L-K.

In some embodiments, L is a C₁-C₇alkyl. In some embodiments, L isheteroalkyl. In certain embodiments, L is C₁-C₇alkyl-aryl. In someembodiments, L is C₁-C₇alkyl-aryl-C₁-C₇alkyl.

In certain embodiments, K is a non-protic charged group. In somespecific embodiments, each K is a ammonium group. In some embodiments,each K is a cyclic non-protic ammonium group. In some embodiments, eachK is an acyclic non-protic ammonium group.

In certain embodiments, each K is a cyclic non-protic ammonium group ofstructure:

In certain embodiments, K is an acyclic non-protic ammonium group ofstructure:

wherein p, q, R⁹, R¹⁰ and Z are as defined above. In certainembodiments, p is 1. In other embodiments, p is 2. In furtherembodiments, p is 3. In some embodiments, q is 0. In other embodiments,q is 1. In some other embodiments, q is 2.

The compounds further comprise 1, 2, 3 or 4 anionic counterions selectedfrom Cl⁻, Br⁻, I⁻, R¹¹SO₃ ⁻, (SO₃ ⁻—R¹¹—SO₃ ⁻), R¹¹CO₂ ⁻, (CO₂ ⁻—R¹¹—CO₂⁻), (R¹¹)₂(P═O)O⁻ and (R¹¹)(P═O)O₂ ²⁻ wherein R₁₁ is as defined above.In some embodiments, the counterion is Cl⁻, Br⁻, I⁻, CH₂CO₂ ⁻, CH₃SO₃ ⁻,or C₆H₅SO₃ ⁻ or CO₂ ⁻—(CH₂)₂—CO₂ ⁻. In some embodiments, the compound ofFormula III has one K group and one counterion. In other embodiments,the compound of Formula III has one K group, and two molecules of thecompound of Formula III have one counterion. In yet other embodiments,the compound of Formula III has two K groups and two counterions. Insome other embodiments, the compound of Formula III has one K groupcomprising two ammonium groups and two counterions.

Also described herein are compounds having the Formula IIIA:

wherein:

each R¹, R² is independently H, substituted or unsubstituted alkyl, or-L-K; or R¹ and R² together with the nitrogen to which they are attachedform a 3-8-membered ring that is optionally substituted with R⁸;

and R³, R⁴, R, L and K are as defined above.

In some embodiments of compounds of Formula IIIA, L is A_(n), whereineach A is substituted or unsubstituted alkyl, or substituted orunsubstituted heteroalkyl, and n is 0-7. In certain specific embodimentsof the compound of Formula IIIA, R¹ is H. In some embodiments of FormulaIIIA, R¹ and R² together with the nitrogen to which they are attachedform a 3-8-membered ring that is optionally substituted with -L-K.

Also described herein are compounds having the Formula IIIB:

wherein:

each R³, R⁴ is independently H, substituted or unsubstituted alkyl,substituted or unsubstituted heteroalkyl, substituted or unsubstitutedaryl, substituted or unsubstituted alkyl-aryl, or -L-K;

and R¹, R², L and K are as defined above.

In certain embodiments of Formula IIIB, R³ is H. In certain embodiments,R³ and R⁴ are each -L-K. In some embodiments, R³ is H and R⁴ issubstituted or unsubstituted alkyl, substituted or unsubstitutedheteroalkyl, substituted or unsubstituted aryl, substituted orunsubstituted alkyl-aryl containing one or two -L-K groups.

In some embodiments, an ASBTI suitable for the methods described hereinis a compound of Formula IIIC

wherein:

each R¹, R² is independently H, hydroxy, alkyl, alkoxy, —C(═X)YR⁸,—YC(═X)R⁸, substituted or unsubstituted alkyl, substituted orunsubstituted heteroalkyl, substituted or unsubstituted aryl,substituted or unsubstituted alkyl-aryl, substituted or unsubstitutedcycloalkyl, substituted or unsubstituted alkyl-cycloalkyl, substitutedor unsubstituted heteroaryl, substituted or unsubstitutedalkyl-heteroaryl, substituted or unsubstituted heterocycloalkyl,substituted or unsubstituted alkyl-heterocycloalkyl, or -L-K; or R¹ andR² together with the nitrogen to which they are attached form a3-8-membered ring that is optionally substituted with R⁸;

each R³, R⁴ is independently H, hydroxy, alkyl, alkoxy, —C(═X)YR⁸,—YC(═X)R⁸, substituted or unsubstituted alkyl, substituted orunsubstituted heteroalkyl, substituted or unsubstituted aryl,substituted or unsubstituted alkyl-aryl, substituted or unsubstitutedcycloalkyl, substituted or unsubstituted alkyl-cycloalkyl, substitutedor unsubstituted heteroaryl, substituted or unsubstitutedalkyl-heteroaryl, substituted or unsubstituted heterocycloalkyl,substituted or unsubstituted alkyl-heterocycloalkyl, or -L-K;

R⁵ is H, hydroxy, alkyl, alkoxy, —C(═X)YR⁸, —YC(═X)R⁸, substituted orunsubstituted alkyl, substituted or unsubstituted heteroalkyl,substituted or unsubstituted aryl, substituted or unsubstitutedalkyl-aryl, substituted or unsubstituted cycloalkyl, substituted orunsubstituted alkyl-cycloalkyl, substituted or unsubstituted heteroaryl,substituted or unsubstituted alkyl-heteroaryl, substituted orunsubstituted heterocycloalkyl, substituted or unsubstitutedalkyl-heterocycloalkyl,

each R⁶, R⁷ is independently H, hydroxy, alkyl, alkoxy, —C(═X)YR⁸,—YC(═X)R⁸, substituted or unsubstituted alkyl, substituted orunsubstituted heteroalkyl, substituted or unsubstituted aryl,substituted or unsubstituted alkyl-aryl, substituted or unsubstitutedcycloalkyl, substituted or unsubstituted alkyl-cycloalkyl, substitutedor unsubstituted heteroaryl, substituted or unsubstitutedalkyl-heteroaryl, substituted or unsubstituted heterocycloalkyl,substituted or unsubstituted alkyl-heterocycloalkyl, or -L-K; or R⁶ andR⁷ taken together form a bond;

each X is independently NH, S, or O;

each Y is independently NH, S, or O;

R⁸ is substituted or unsubstituted alkyl, substituted or unsubstitutedheteroalkyl, substituted or unsubstituted aryl, substituted orunsubstituted alkyl-aryl, substituted or unsubstituted cycloalkyl,substituted or unsubstituted alkyl-cycloalkyl, substituted orunsubstituted heteroaryl, substituted or unsubstituted alkyl-heteroaryl,substituted or unsubstituted heterocycloalkyl, substituted orunsubstituted alkyl-heterocycloalkyl, or -L-K;

L is A_(n), wherein

each A is independently NR¹, S(O)_(m), O, C(═X)Y, Y(C═X), substituted orunsubstituted alkyl, substituted or unsubstituted heteroalkyl,substituted or unsubstituted aryl, substituted or unsubstitutedheteroaryl, substituted or unsubstituted cycloalkyl, or substituted orunsubstituted heterocycloalkyl; wherein each m is independently 0-2;

n is 0-7;

K is a moiety that prevents systemic absorption;

or a pharmaceutically acceptable salt thereof.

In some specific embodiments of Formula I, II or III, K is selected from

In some embodiments, an ASBTI suitable for the methods described hereinis a compound of Formula IV:

wherein

R¹ is a straight chain C₁₋₆ alkyl group;

R² is a straight chain C₁₋₆ alkyl group;

R³ is hydrogen or a group OR₁₁ in which R¹¹ is hydrogen, optionallysubstituted C₁₋₆ alkyl or a C₁₋₆ alkylcarbonyl group;

R⁴ is pyridyl or an optionally substituted phenyl;

R⁵, R⁶ and R⁸ are the same or different and each is selected from:

hydrogen, halogen, cyano, R¹⁵-acetylide, OR¹⁵, optionally substitutedC₁₋₆ alkyl, COR¹⁵, CH(OH)R¹⁵, S(O)_(n)R¹⁵, P(O)(OR¹⁵)₂, OCOR¹⁵, OCF₃,OCN, SCN, NHCN, CH₂OR¹⁵, CHO, (CH₂)_(p)CN, CONR¹²R¹³, (CH₂)_(p)CO₂R¹⁵,(CH₂)_(p)NR¹²R¹³, CO₂R¹⁵, NHCOCF₃, NHSO₂R¹⁵, OCH₂OR¹⁵, OCH═CHR¹⁵,O(CH₂CH₂O)_(n)R¹⁵, O(CH₂)_(p)SO₃R¹⁵, O(CH₂)_(p)NR¹²R¹³ andO(CH₂)_(p)N⁺R¹²R¹³R¹⁴ wherein

p is an integer from 1-4,

n is an integer from 0-3 and

R¹², R¹³, R¹⁴ and R¹⁵ are independently selected from hydrogen andoptionally substituted C¹⁻⁶ alkyl;

R⁷ is a group of the formula

wherein the hydroxyl groups may be substituted by acetyl, benzyl,

or —(C₁-C₆)-alkyl-R¹⁷,

wherein the alkyl group may be substituted with one or more hydroxylgroups;

R¹⁶ is —COOH, —CH₂—OH, —CH₂—O-Acetyl, —COOMe or —COOEt;

R¹⁷ is H, —OH, —NH₂, —COOH or COOR¹⁸;

R¹⁸ is (C₁-C₄)-alkyl or —NH—(C₁-C₄)-alkyl;

X is —NH— or —O—; and

R⁹ and R¹⁰ are the same or different and each is hydrogen or C₁-C₆alkyl; and salts thereof.

In some embodiments, a compound of Formula IV has the structure ofFormula IVA or Formula IVB:

In some embodiments, a compound of Formula IV has the structure ofFormula IVC:

In some embodiments of Formula IV, X is O and R⁷ is selected from

In some embodiments, a compound of Formula IV is:

In some embodiments, an ASBTI suitable for the methods described hereinis a compound of Formula V:

wherein:

R^(v) is selected from hydrogen or C₁₋₆alkyl;

One of R¹ and R² are selected from hydrogen or C₁₋₆alkyl and the otheris selected from C₁₋₆alkyl;

R^(x) and R^(y) are independently selected from hydrogen, hydroxy,amino, mercapto, C₁₋₆alkyl, C₁₋₆alkoxy, N—(C₁₋₆alkyl)amino,N,N—(C₁₋₆alkyl)₂amino, C₁₋₆alkylS(O)_(a) wherein a is 0 to 2;

R^(z) is selected from halo, nitr, cyano, hydroxy, amino, carboxy,carbamoyl, mercapto, sulphamoyl, C₁₋₆alkyl, C₂₋₆alkenyl, C₂₋₆alkynyl,C₁₋₆alkoxy, C₁₋₆alkanoyl, C₁₋₆alkanoyloxy, N—(C₁₋₆alkyl)amino,N,N—(C₁₋₆alkyl)₂amino, C₁₋₆alkanoylamino, N—(C₁₋₆alkyl)carbamoyl,N,N—(C₁₋₆alkyl)₂carbamoyl, C₁₋₆alkylS(O)_(a) wherein a is 0 to 2,C₁₋₆alkoxycarbonyl, N—(C₁₋₆-alkyl)sulphamoyl andN,N—(C₁₋₆alkyl)₂sulphamoyl;

n is 0-5;

one of R⁴ and R⁵ is a group of formula (VA):

R³ and R⁶ and the other of R⁴ and R⁵ are independently selected fromhydrogen, halo, nitro, cyano, hydroxy, amino, carboxy, carbamoyl,mercapto, sulphamoyl, C₁₋₆alkyl, C₂₋₆alkenyl, C₂₋₆alkynyl, C₁₋₆alkoxy,C₁₋₆alkanoyl, C₁₋₆alkanoyloxy, N—(C₁₋₆alkyl)amino,N,N—(C₁₋₆alkyl)₂amino, C₁₋₆alkanoylamino, N—(C₁₋₆alkyl)carbamoyl,N,N—(C₁₋₆alkyl)₂carbamoyl, C₁₋₆alkylS(O)_(a) wherein a is 0 to 2,C₁₋₆alkoxycarbonyl, N—(C₁₋₆alkyl)sulphamoyl andN,N—(C₁₋₆alkyl)₂sulphamoyl;

wherein R³ and R⁶ and the other of R⁴ and R⁵ may be optionallysubstituted on carbon by one or more R¹⁷;

X is —O—, —N(R^(a))—, —S(O)^(b)— or —CH(R^(a))—;

wherein R^(a) is hydrogen or C₁₋₆alkyl and b is 0-2;

Ring A is aryl or heteroaryl;

wherein Ring A is optionally substituted on carbon by one or moresubstituents selected from R¹⁸;

R is hydrogen, C₁₋₆alkyl, carbocyclyl or heterocyclyl;

wherein R⁷ is optionally substituted on carbon by one or moresubstituents selected from R¹⁹; and wherein if said heterocyclylcontains an —NH— group, that nitrogen may be optionally substituted by agroup selected from R²⁰;

R⁸ is hydrogen or C₁₋₆-alkyl;

R⁹ is hydrogen or C₁₋₆alkyl;

R¹⁰ is hydrogen, halo, nitro, cyano, hydroxy, amino, carbamoyl,mercapto, sulphamoyl, hydroxyaminocarbonyl, C₁₋₁₀alkyl, C₂₋₁₀alkynyl,C₂₋₁₀alkynyl, C₁₋₁₀alkoxy, C₁₋₁₀alkanoyl, C₁₋₁₀alkanoyloxy,N—(C₁₋₁₀alkyl)amino, N,N—(C₁₋₁₀alkyl)₂amino, N,N,N—(C₁₋₁₀alkyl)₃ammonio,C₁₋₁₀alkanoylamino, N—(C₁₋₁₀alkyl)carbamoyl, N,N—(C₁₋₁₀alkyl)₂carbamoyl,C₁₋₁₀alkylS(O)_(a) wherein a is 0 to 2, N—(C₁₋₁₀alkyl)sulphamoyl,N,N—(C₁₋₁₀alkyl)₂sulphamoyl, N—(C₁₋₁₀alkyl)sulphamoylamino,N,N—(C₁₋₁₀alkyl)₂sulphamoylamino, C₁₋₁₀alkoxycarbonylamino, carbocyclyl,carbocyclylC₁₋₁₀alkyl, heterocyclyl, heterocyclylC₁₋₁₀alkyl,carbocyclyl-(C₁₋₁₀alkylene)_(p)-R²¹—(C₁₋₁₀alkylene)_(q)- orheterocyclyl-(C₁₋₁₀alkylene)_(r)-R²²—(C₁₋₁₀alkylene)_(s)-; wherein R¹⁰is optionally substituted on carbon by one or more substituents selectedfrom R²³; and wherein if said heterocyclyl contains an —NH— group, thatnitrogen may be optionally substituted by a group selected from R²⁴; orR¹⁰ is a group of formula (VB):

wherein:

R¹¹ is hydrogen or C₁₋₆-alkyl;

R¹² and R¹³ are independently selected from hydrogen, halo, carbamoyl,sulphamoyl, C₁₋₁₀alkyl, C₂₋₁₀alkynyl, C₂₋₁₀alkynyl, C₁₋₁₀alkanoyl,N—(C₁₋₁₀alkyl)carbamoyl, N,N—(C₁₋₁₀alkyl)₂carbamoyl, C₁₋₁₀alkylS(O)_(a)wherein a is 0 to 2, N—(C₁₋₁₀alkyl)sulphamoyl,N,N—(C₁₋₁₀alkyl)₂sulphamoyl, N—(C₁₋₁₀alkyl)sulphamoylamino,N,N—(C₁₋₁₀alkyl)₂sulphamoylamino, carbocyclyl or heterocyclyl; whereinR¹² and R¹³ may be independently optionally substituted on carbon by oneor more substituents selected from R²⁵; and wherein if said heterocyclylcontains an —NH— group, that nitrogen may be optionally substituted by agroup selected from R²⁶;

R¹⁴ is selected from hydrogen, halo, carbamoyl, sulphamoyl,hydroxyaminocarbonyl, C₁₋₁₀alkyl, C₂₋₁₀alkenyl, C₂₋₁₀alkynyl,C₁₋₁₀alkanoyl, N—(C₁₋₁₀alkyl)carbamoyl, N,N—(C₁₋₁₀alkyl)₂carbamoyl,C₁₋₁₀alkylS(O)_(a) wherein a is 0 to 2, N—(C₁₋₁₀alkyl)sulphamoyl,N,N—(C₁₋₁₀alkyl)₂sulphamoyl, N—(C₁₋₁₀alkyl)sulphamoylamino,N,N—(C₁₋₁₀alkyl)₂sulphamoylamino, carbocyclyl, carbocyclylC₁₋₁₀alkyl,heterocyclyl, heterocyclylC₁₋₁₀alkyl,carbocyclyl-(C₁₋₁₀alkylene)_(p)-R²⁷—(C₁₋₁₀alkylene)_(q)- orheterocyclyl-(C₁₋₁₀alkylene)_(r)-R²⁸—(C₁₋₁₀alkylene)_(s)-; wherein R¹⁴may be optionally substituted on carbon by one or more substituentsselected from R²⁹; and wherein if said heterocyclyl contains an —NH—group, that nitrogen may be optionally substituted by a group selectedfrom R³⁰; or R¹⁴ is a group of formula (VC):

R¹⁵ is hydrogen or C₁₋₆alkyl; and R¹⁶ is hydrogen or C₁₋₆alkyl; whereinR¹⁶ may be optionally substituted on carbon by one or more groupsselected from R³¹.

or R¹⁵ and R¹⁶ together with the nitrogen to which they are attachedform a heterocyclyl; wherein said heterocyclyl may be optionallysubstituted on carbon by one or more R³⁷; and wherein if saidheterocyclyl contains an —NH— group, that nitrogen may be optionallysubstituted by a group selected from R³⁸;

m is 1-3; wherein the values of R⁷ may be the same or different;

R¹⁷, R¹⁸, R¹⁹, R²³, R²⁵, R²⁹, R³¹ and R³⁷ are independently selectedfrom halo, nitro, cyano, hydroxy, amino, carbamoyl, mercapto,sulphamoyl, hydroxyaminocarbonyl, C₁₋₁₀alkyl, C₂₋₁₀alkenyl,C₂₋₁₀alkynyl, C₁₋₁₀alkoxy, C₁₋₁₀alkanoyl, C₁₋₁₀alkanoyloxy,N—(C₁₋₁₀alkyl)amino, N,N—(C₁₋₁₀alkyl)₂amino, N,N,N—(C₁₋₁₀alkyl)₃ammonio,C₁₋₁₀alkanoylamino, N—(C₁₋₁₀alkyl)carbamoyl, N,N—(C₁₋₁₀alkyl)₂carbamoyl,C₁₋₁₀alkylS(O)_(a) wherein a is 0 to 2, N—(C₁₋₁₀alkyl)sulphamoyl,N,N—(C₁₋₁₀alkyl)₂sulphamoyl, N—(C₁₋₁₀alkyl)sulphamoylamino,N,N—(C₁₋₁₀alkyl)₂sulphamoylamino, C₁₋₁₀alkoxycarbonylamino, carbocyclyl,carbocyclylC₁₋₁₀alkyl, heterocyclyl, heterocyclylC₁₋₁₀alkyl,carbocyclyl-(C₁₋₁₀alkylene)_(p)-R³²—(C₁₋₁₀alkylene)_(q)- orheterocyclyl-(C₁₋₁₀alkylene)_(r)-R³³—(C₁₋₁₀alkylene)_(s)-; wherein R¹⁷,R¹⁸, R¹⁹, R²³, R²⁵, R²⁹, R³¹ and R³⁷ may be independently optionallysubstituted on carbon by one or more R³⁴; and wherein if saidheterocyclyl contains an —NH— group, that nitrogen may be optionallysubstituted by a group selected from R³⁵;

R²¹, R²², R²⁷, R²⁸, R³² or R³³ are independently selected from —O—,—NR³⁶—S(O)_(x)—, —NR³⁶C(O)NR³⁶—, —NR³⁶C(S)NR³⁶—, —OC(O)N═C—, —NR³⁶C(O)—or —C(O)NR³⁶—; wherein R³⁶ is selected from hydrogen or C₁₋₆alkyl, and xis 0-2;

p, q, r and s are independently selected from 0-2;

R³⁴ is selected from halo, hydroxy, cyano, carbamoyl, ureido, amino,nitro, carbamoyl, mercapto, sulphamoyl, trifluoromethyl,trifluoromethoxy, methyl, ethyl, methoxy, ethoxy, vinyl, allyl, ethynyl,formyl, acetyl, formamido, acetylamino, acetoxy, methylamino,dimethylamino, N-methylcarbamoyl, N,N-dimethylcarbamoyl, methylthio,methylsulphinyl, mesyl, N-methylsulphamoyl, N,N-dimethylsulphamoyl,N-methylsulphamoylamino and N,N-dimethylsulphamoylamino;

R²⁰, R²⁴, R²⁶, R³⁰, R³⁵ and R³⁸ are independently selected fromC₁₋₆alkyl, C₁₋₆alkanoyl, C₁₋₆alkylsulphonyl, C₁₋₆alkoxycarbonyl,carbamoyl, N—(C₁₋₆alkyl)carbamoyl, N,N—(C₁₋₆alkyl)carbamoyl, benzyl,benzyloxycarbonyl, benzoyl and phenylsulphonyl; and

wherein a “heteroaryl” is a totally unsaturated, mono or bicyclic ringcontaining 3-12 atoms of which at least one atom is chosen fromnitrogen, sulphur and oxygen, which heteroaryl may, unless otherwisespecified, be carbon or nitrogen linked;

wherein a “heterocyclyl” is a saturated, partially saturated orunsaturated, mono or bicyclic ring containing 3-12 atoms of which atleast one atom is chosen from nitrogen, sulphur and oxygen, whichheterocyclyl may, unless otherwise specified, be carbon or nitrogenlinked, wherein a —CH₂— group can optionally be replaced by a —C(O)—group, and a ring sulphur atom may be optionally oxidised to form anS-oxide; and

wherein a “carbocyclyl” is a saturated, partially saturated orunsaturated, mono or bicyclic carbon ring that contains 3-12 atoms;wherein a —CH₂— group can optionally be replaced by a —C(O) group;

or a pharmaceutically acceptable salt or in vivo hydrolysable ester oramide formed on an available carboxy or hydroxy group thereof.

In some embodiments, compound of Formula V is1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N—{(R)-α-[N—((R)-1-carboxy-2-methylthio-ethyl)carbamoyl]-4-hydroxybenzyl}carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine;1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N—{(R)-α-[N—((S)-1-carboxy-2-(R)-hydroxypropyl)carbamoyl]-4-hydroxybenzyl}carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine;1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N—{(R)-α-[N—((S)-1-carboxy-2-methylpropyl)carbamoyl]-4-hydroxybenzyl}carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine;1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N—{(R)-α-[N—((S)-1-carboxybutyl)carbamoyl]-4-hydroxybenzyl}carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine;1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N—{(R)-α-[N—((S)-1-carboxypropyl)carbamoyl]benzyl}carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine;1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N—{(R)-α-[N—((S)-1-carboxyethyl)carbamoyl]benzyl}carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine;1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N—{(R)-α-[N—((S)-1-carboxy-2-(R)-hydroxypropyl)carbamoyl]benzyl}carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine;1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N—{(R)-α-[N-(2-sulphoethyl)carbamoyl]-4-hydroxybenzyl}carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine;1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N—{(R)-α-[N—((S)-1-carboxyethyl)carbamoyl]-4-hydroxybenzyl}carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine;1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N—{(R)-α-[N—((R)-1-carboxy-2-methylthioethyl)carbamoyl]benzyl}carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine;1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N—{(R)-α-[N—{(S)-1-[N—((S)-2-hydroxy-1-carboxyethyl)carbamoyl]propyl}carbamoyl]benzyl}carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine;1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N—{(R)-α-[N—((S)-1-carboxy-2-methylpropyl)carbamoyl]benzyl}carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine;1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N—{(R)-α-[N—((S)-1-carboxypropyl)carbamoyl]-4-hydroxybenzyl}carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine;1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-[N—{(R)-α-carboxy4-hydroxybenzyl}carbamoylmethoxy]-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine;or1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N—{(R)-α-[N-(carboxymethyl)carbamoyl]benzyl}carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine, or a saltthereof.

In some embodiments, compound of Formula V is

In some embodiments, an ASBTI suitable for the methods described hereinis a compound of Formula VI:

wherein:

R^(v) and R^(w) are independently selected from hydrogen or C₁₋₆alkyl;

one of R¹ and R² is selected from hydrogen or C₁₋₆alkyl and the other isselected from C₁₋₆alkyl;

R^(x) and R^(y) are independently selected from hydrogen or C₁₋₆alkyl,or one of R^(x) and R^(y) is hydrogen or C₁₋₆alkyl and the other ishydroxy or C₁₋₆alkoxy;

R^(z) is selected from halo, nitro, cyano, hydroxy, amino, carboxy,carbamoyl, mercapto, sulphamoyl, C₁₋₆alkyl, C₂₋₆alkenyl, C₂₋₆alkynyl,C₁₋₆alkoxy, C₁₋₆alkanoyl, C₁₋₆alkanoyloxy, N—(C₁₋₆alkyl)amino,N,N—(C₁₋₆alkyl)₂amino, C₁₋₆alkanoylamino, N—(C₁₋₆alkyl)carbamoyl,N,N—(C₁₋₆alkyl)₂carbamoyl, C₁₋₆alkylS(O)_(a) wherein a is 0 to 2,C₁₋₆alkoxycarbonyl, N—(C₁₋₆alkyl)sulphamoyl andN,N—(C₁₋₆alkyl)₂sulphamoyl;

n is 0-5;

one of R⁴ and R⁵ is a group of formula (VIA):

R³ and R⁶ and the other of R⁴ and R⁵ are independently selected fromhydrogen, halo, nitro, cyano, hydroxy, amino, carboxy, carbamoyl,mercapto, sulphamoyl, C₁₋₆alkyl, C₂₋₆alkenyl, C₂₋₆alkynyl, C₁₋₆alkoxy,C₁₋₆alkanoyl, C₁₋₆alkanoyloxy, N—(C₁₋₆alkyl)amino,N,N—(C₁₋₆alkyl)₂amino, C₁₋₆alkanoylamino, N—(C₁₋₆alkyl)carbamoyl,N,N—(C₁₋₆alkyl)₂carbamoyl, C₁₋₆alkylS(O)_(a) wherein a is 0 to 2,C₁₋₆alkoxycarbonyl, N—(C₁₋₆alkyl)sulphamoyl andN,N—(C₁₋₆alkyl)₂sulphamoyl; wherein R³ and R⁶ and the other of R⁴ and R⁵may be optionally substituted on carbon by one or more R¹⁷;

X is —O—, —N(R^(a))—, —S(O)^(b)— or —CH(R^(a))—; wherein R^(a) ishydrogen or C₁₋₆alkyl and b is 0-2;

Ring A is aryl or heteroaryl; wherein Ring A is optionally substitutedon carbon by one or more substituents selected from R¹⁸;

R⁷ is hydrogen, C₁₋₆alkyl, carbocyclyl or heterocyclyl; wherein R⁷ isoptionally substituted on carbon by one or more substituents selectedfrom R¹⁹; and wherein if said heterocyclyl contains an —NH— group, thatnitrogen may be optionally substituted by a group selected from R²⁰;

R⁸ is hydrogen or C₁₋₆alkyl;

R⁹ is hydrogen or C₁₋₆alkyl;

R¹⁰ is hydrogen, halo, nitro, cyano, hydroxy, amino, carbamoyl,mercapto, sulphamoyl, hydroxyaminocarbonyl, C₁₋₁₀alkyl, C₂₋₁₀alkenyl,C₂₋₁₀alkynyl, C₁₋₁₀alkoxy, C₁₋₁₀alkanoyl, C₁₋₁₀alkanoyloxy,N—(C₁₋₁₀alkyl)amino, N,N—(C₁₋₁₀alkyl)₂amino, N,N,N—(C₁₋₁₀alkyl)₃ammonio,C₁₋₁₀alkanoylamino, N—(C₁₋₁₀alkyl)carbamoyl, N,N—(C₁₋₁₀alkyl)₂carbamoyl,C₁₋₁₀alkylS(O)_(a) wherein a is 0 to 2, N—(C₁₋₁₀alkyl)sulphamoyl,N,N—(C₁₋₁₀alkyl)₂sulphamoyl, N—(C₁₋₁₀alkyl)sulphamoylamino,N,N—(C₁₋₁₀alkyl)₂sulphamoylamino, C₁₋₁₀alkoxycarbonylamino, carbocyclyl,carbocyclylC₁₋₁₀alkyl, heterocyclyl, heterocyclylC₁₋₁₀alkyl,carbocyclyl-(C₁₋₁₀alkylene)_(p)-R²¹—(C₁₋₁₀alkylene)_(q)- orheterocyclyl-(C₁₋₁₀alkylene)_(r)-R²²—(C₁₋₁₀alkylene)_(s)-; wherein R¹⁰is optionally substituted on carbon by one or more substituents selectedfrom R²³; and wherein if said heterocyclyl contains an —NH— group, thatnitrogen may be optionally substituted by a group selected from R²⁴; orR¹⁰ is a group of formula (VIB):

wherein:

R₁₁ is hydrogen or C₁₋₆alkyl;

R¹² and R¹³ are independently selected from hydrogen, halo, nitro,cyano, hydroxy, amino, carbamoyl, mercapto, sulphamoyl, C₁₋₁₀alkyl,C₂₋₁₀alkenyl, C₂₋₁₀alkynyl, C₁₋₁₀alkoxy, C₁₋₁₀alkanoyl,C₁₋₁₀alkanoyloxy, N—(C₁₋₁₀alkyl)amino, N,N—(C₁₋₁₀alkyl)₂amino,C₁₋₁₀alkanoylamino, N—(C₁₋₁₀alkyl)carbamoyl, N,N—(C₁₋₁₀alkyl)₂carbamoyl,C₁₋₁₀alkylS(O)_(a) wherein a is 0 to 2, N—(C₁₋₁₀alkyl)sulphamoyl,N,N—(C₁₋₁₀alkyl)₂sulphamoyl, N—(C₁₋₁₀alkyl)sulphamoylamino,N,N—(C₁₋₁₀alkyl)₂sulphamoylamino, carbocyclyl or heterocyclyl; whereinR¹² and R¹³ may be independently optionally substituted on carbon by oneor more substituents selected from R²⁵; and wherein if said heterocyclylcontains an —NH— group, that nitrogen may be optionally substituted by agroup selected from R²⁶;

R¹⁴ is selected from hydrogen, halo, nitro, cyano, hydroxy, amino,carbamoyl, mercapto, sulphamoyl, hydroxyaminocarbonyl, C₁₋₁₀alkyl,C₂₋₁₀alkenyl, C₂₋₁₀alkynyl, C₁₋₁₀alkoxy, C₁₋₁₀alkanoyl,C₁₋₁₀alkanoyloxy, N—(C₁₋₁₀alkyl)amino, N,N—(C₁₋₁₀alkyl)₂amino,N,N,N—(C₁₋₁₀alkyl)₃ammonio, C₁₋₁₀alkanoylamino, N—(C₁₋₁₀alkyl)carbamoyl,N,N—(C₁₋₁₀alkyl)₂carbamoyl, C₁₋₁₀alkylS(O)_(a) wherein a is 0 to 2,N—(C₁₋₁₀alkyl)sulphamoyl, N,N—(C₁₋₁₀alkyl)₂sulphamoyl,N—(C₁₋₁₀alkyl)sulphamoylamino, N,N—(C₁₋₁₀alkyl)₂sulphamoylamino,C₁₋₁₀alkoxycarbonylamino, carbocyclyl, carbocyclylC₁₋₁₀alkyl,heterocyclyl, heterocyclylC₁₋₁₀alkyl,carbocyclyl-(C₁₋₁₀alkylene)_(p)-R²⁷—(C₁₋₁₀alkylene)_(q)- orheterocyclyl-(C₁₋₁₀alkylene)_(r)-R²⁸—(C₁₋₁₀alkylene)_(s)-; wherein R¹⁴may be optionally substituted on carbon by one or more substituentsselected from R²⁹; and wherein if said heterocyclyl contains an —NH—group, that nitrogen may be optionally substituted by a group selectedfrom R³⁰; or R¹⁴ is a group of formula (VIC):

R¹⁵ is hydrogen or C₁₋₆alkyl;

R¹⁶ is hydrogen or C₁₋₆alkyl; wherein R¹⁶ may be optionally substitutedon carbon by one or more groups selected from R³¹;

n is 1-3; wherein the values of R⁷ may be the same or different;

R¹⁷, R¹⁸, R¹⁹, R²³, R²⁵, R²⁹ or R³¹ are independently selected fromhalo, nitro, cyano, hydroxy, amino, carbamoyl, mercapto, sulphamoyl,hydroxyaminocarbonyl, amidino, C₁₋₁₀alkyl, C₂₋₁₀alkenyl, C₂₋₁₀alkynyl,C₁₋₁₀alkoxy, C₁₋₁₀alkanoyl, C₁₋₁₀alkanoyloxy, (C₁₋₁₀alkyl)₃silyl,N—(C₁₋₁₀alkyl)amino, N,N—(C₁₋₁₀alkyl)₂amino, N,N,N—(C₁₋₁₀alkyl)₃ammonio,C₁₋₁₀alkanoylamino, N—(C₁₋₁₀alkyl)carbamoyl, N,N—(C₁₋₁₀alkyl)₂carbamoyl,C₁₋₁₀alkylS(O)_(a) wherein a is 0 to 2, N—(C₁₋₁₀alkyl)sulphamoyl,N,N—(C₁₋₁₀alkyl)₂sulphamoyl, N—(C₁₋₁₀alkyl)sulphamoylamino,N,N—(C₁₋₁₀alkyl)₂sulphamoylamino, C₁₋₁₀alkoxycarbonylamino, carbocyclyl,carbocyclylC₁₋₁₀alkyl, heterocyclyl, heterocyclylC₁₋₁₀alkyl,carbocyclyl-(C₁₋₁₀alkylene)_(p)-R³²—(C₁₋₁₀alkylene)_(q)- orheterocyclyl-(C₁₋₁₀alkylene)_(r)-R³³—(C₁₋₁₀alkylene)_(s)-; wherein R¹⁷,R¹⁸, R¹⁹, R²³, R²⁵, R²⁹ or R³¹ may be independently optionallysubstituted on carbon by one or more R³⁴; and wherein if saidheterocyclyl contains an —NH— group, that nitrogen may be optionallysubstituted by a group selected from R³⁵;

R²¹, R²², R²⁷, R²⁸, R³² or R³³ are independently selected from —O—,—NR³⁶—S(O)_(x)—, —NR³⁶C(O)NR³⁶—, —NR³⁶C(S)NR³⁶—, —OC(O)N═C—, —NR³⁶C(O)—or —C(O)NR³⁶—; wherein R³⁶ is selected from hydrogen or C₁₋₆alkyl, and xis 0-2;

p, q, r and s are independently selected from 0-2;

R³⁴ is selected from halo, hydroxy, cyano, carbamoyl, ureido, amino,nitro, carbamoyl, mercapto, sulphamoyl, trifluoromethyl,trifluoromethoxy, methyl, ethyl, methoxy, ethoxy, vinyl, allyl, ethynyl,formyl, acetyl, formamido, acetylamino, acetoxy, methylamino,dimethylamino, N-methylcarbamoyl, N,N-dimethylcarbamoyl, methylthio,methylsulphinyl, mesyl, N-methylsulphamoyl, N,N-dimethylsulphamoyl,N-methylsulphamoylamino and N,N-dimethylsulphamoylamino;

R²⁰, R²⁴, R²⁶, R³⁰ or R³⁵ are independently selected from C₁₋₆alkyl,C₁₋₆alkanoyl, C₁₋₆alkylsulphonyl, C₁₋₆alkoxycarbonyl, carbamoyl,N—(C₁₋₆alkyl)carbamoyl, N,N—(C₁₋₆alkyl)carbamoyl, benzyl,benzyloxycarbonyl, benzoyl and phenylsulphonyl;

or a pharmaceutically acceptable salt, solvate or solvate of such asalt, or an in vivo hydrolysable ester formed on an available carboxy orhydroxy thereof, or an in vivo hydrolysable amide formed on an availablecarboxy thereof.

In some embodiments, a compound of Formula VI has the structure ofFormula VID:

wherein:

R¹ and R² are independently selected from C₁₋₆alkyl; one of R⁴ and R⁵ isa group of formula (VIE):

R³ and R⁶ and the other of R⁴ and R⁵ are independently selected fromhydrogen, halo, nitro, cyano, hydroxy, amino, carboxy, carbamoyl,mercapto, sulphamoyl, C₁₋₄alkyl, C₂₋₄alkenyl, C₂₋₄alkynyl, C₁₋₄alkoxy,C₁₋₄alkanoyl, C₁₋₄alkanoyloxy, N—(C₁₋₄alkyl)amino,N,N—(C₁₋₄alkyl)₂amino, C₁₋₄alkanoylamino, N—(C₁₋₄alkyl)carbamoyl,N,N—(C₁₋₄alkyl)₂carbamoyl, C₁₋₄alkylS(O)_(a) wherein a is 0 to 2,C₁₋₄alkoxycarbonyl, N—(C₁₋₄alkyl)sulphamoyl andN,N—(C₁₋₄alkyl)₂sulphamoyl; wherein R³ and R⁶ and the other of R⁴ and R⁵may be optionally substituted on carbon by one or more R¹⁴;

R⁷ is carboxy, sulpho, sulphino, phosphono, —P(O)(OR^(a))(OR^(b)),P(O)(OH)(OR_(a)), —P(O)(OH)(R^(a)) or P(O)(OR^(a))(R^(b)), wherein R^(a)and R^(b) are independently selected from C₁₋₆alkyl; or R⁷ is a group offormula (VIF):

R⁸ and R⁹ are independently hydrogen, C₁₋₄alkyl or a saturated cyclicgroup, or R⁸ and R⁹ together form C₂₋₆alkylene; wherein R⁸ and R⁹ or R⁸and R⁹ together may be independently optionally substituted on carbon byone or more substituents selected from R¹⁵; and wherein if saidsaturated cyclic group contains an —NH— moiety, that nitrogen may beoptionally substituted by one or more R²⁰;

R¹⁰ is hydrogen or C₁₋₄alkyl; wherein R¹⁰ is optionally substituted oncarbon by one or more substituents selected from R²⁴;

R¹¹ is hydrogen, C¹⁻⁴alkyl, carbocyclyl or heterocyclyl; wherein R¹¹ isoptionally substituted on carbon by one or more substituents selectedfrom R¹⁶; and wherein if said heterocyclyl contains an —NH— moiety, thatnitrogen may be optionally substituted by one or more R²¹;

R¹² is hydrogen or C₁₋₄alkyl, carbocyclyl or heterocyclyl; wherein R¹²optionally substituted on carbon by one or more substituents selectedfrom R¹⁷; and wherein if said heterocyclyl contains an —NH— moiety, thatnitrogen may be optionally substituted by one or more R²²;

R¹³ is carboxy, sulpho, sulphino, phosphono, —P(O)(OR^(c))(OR^(d)),—P(O)(OH)(OR^(c)), —P(O)(OH)(R^(c)) or —P(O)(OR^(c))(R^(d)) whereinR^(c) and R^(d) are independently selected from C₁₋₆alkyl;

m is 1-3; wherein the values of R⁸ and R⁹ may be the same or different;

n is 1-3; wherein the values of R¹¹ may be the same or different;

p is 1-3; wherein the values of R¹² may be the same or different;

R¹⁴ and R¹⁶ are independently selected from halo, nitro, cyano, hydroxy,amino, carboxy, carbamoyl, mercapto, sulphamoyl, C₁₋₄alkyl, C₂₋₄alkenyl,C₂₋₄alkynyl, C₁₋₄alkoxy, C₁₋₄alkanoyl, C₁₋₄alkanoyloxy,N—(C₁₋₄alkyl)amino, N,N—(C₁₋₄alkyl)₂amino, C₁₋₄alkanoylamino,N—(C₁₋₄alkyl)carbamoyl, N,N—(C₁₋₄alkyl)₂carbamoyl, C₁₋₄alkylS(O)_(a)wherein a is 0 to 2, C₁₋₄alkoxycarbonyl, N—(C₁₋₄alkyl)sulphamoyl andN,N—(C₁₋₄alkyl)₂sulphamoyl; wherein R¹⁴ and R¹⁶ may be independentlyoptionally substituted on carbon by one or more R¹⁸.

R¹⁵ and R¹⁷ are independently selected from halo, nitro, cyano, hydroxy,amino, carboxy, carbamoyl, mercapto, sulphamoyl, C₁₋₄alkyl, C₂₋₄alkenyl,C₂₋₄alkynyl, C₁₋₄alkoxy, C₁₋₄alkanoyl, C₁₋₄alkanoyloxy,N—(C₁₋₄alkyl)amino, N,N—(C₁₋₄alkyl)₂amino, C₁₋₄alkanoylamino,N—(C₁₋₄alkyl)carbamoyl, N,N—(C₁₋₄alkyl)₂carbamoyl, C₁₋₄alkylS(O)_(a)wherein a is 0 to 2, C₁₋₄alkoxycarbonyl, N—(C₁₋₄alkyl)sulphamoyl andN,N—(C₁₋₄alkyl)₂sulphamoyl, carbocyclyl, heterocyclyl, sulpho, sulphino,amidino, phosphono, —P(O)(OR^(e))(OR^(f)), —P(O)(OH)(OR^(e)),—P(O)(OH)(R^(e)) or —P(O)(OR^(e))(R^(f)), wherein Wand Blareindependently selected from C₁₋₆alkyl; wherein R¹⁵ and R¹⁷ may beindependently optionally substituted on carbon by one or more R¹⁹; andwherein if said heterocyclyl contains an —NH— moiety, that nitrogen maybe optionally substituted by one or more R²³.

R¹⁸, R¹⁹ and R²⁵ are independently selected from halo, hydroxy, cyano,carbamoyl, ureido amino nitro, carboxy, carbamoyl, mercapto, sulphamoyl,trifluoromethyl, trifluoromethoxy, methyl, ethyl, methoxy, ethoxy,vinyl, allyl, ethynyl, methoxycarbonyl, formyl, acetyl, formamido,acetylamino, acetoxy, methylamino, dimethylamino, N-methylcarbamoyl,N,N-dimethylcarbamoyl, methylthio, methylsulphinyl, mesyl,N-methylsulphamoyl and N,N-dimethylsulphamoyl;

R²⁰, R²¹, R²², R²³ and R²⁶ are independently C₁₋₄alkyl, C₁₋₄alkanoyl,C₁₋₄alkylsulphonyl, sulphamoyl, N—(C₁₋₄alkyl)sulphamoyl,N,N—(C₁₋₄alkyl)₂sulphamoyl, C₁₋₄alkoxycarbonyl, carbamoyl,N—(C₁₋₄alkyl)carbamoyl, N,N—(C₁₋₄alkyl)₂carbamoyl, benzyl, phenethyl,benzoyl, phenylsulphonyl and phenyl;

R²⁴ is selected from halo, nitro, cyano, hydroxy, amino, carboxy,carbamoyl, mercapto, sulphamoyl, C₁₋₄alkyl, C₂₋₄alkenyl, C₂₋₄alkynyl,C₁₋₄alkoxy, C₁₋₄alkanoyl, C₁₋₄alkanoyloxy, N—(C₁₋₄alkyl)amino,N,N—(C₁₋₄alkyl)₂amino, C₁₋₄alkanoylamino, N—(C₁₋₄alkyl)carbamoyl,N,N—(C₁₋₄alkyl)₂carbamoyl, C₁₋₄alkylS(O)_(a) wherein a is 0 to 2,C₁₋₄alkoxycarbonyl, N—(C₁₋₄alkyl)sulphamoyl andN,N—(C₁₋₄alkyl)₂sulphamoyl, carbocyclyl, heterocyclyl; wherein R²⁴ maybe independently optionally substituted on carbon by one or more R²⁵;and wherein if said heterocyclyl contains an —NH— moiety, that nitrogenmay be optionally substituted by one or more R²⁶.

wherein any saturated cyclic group is a totally or partially saturated,mono or bicyclic ring containing 3-12 atoms of which 0-4 atoms arechosen from nitrogen, sulphur or oxygen, which may be carbon or nitrogenlinked;

wherein any heterocyclyl is a saturated, partially saturated orunsaturated, mono or bicyclic ring containing 3-12 atoms of which atleast one atom is chosen from nitrogen, sulphur or oxygen, which may becarbon or nitrogen linked, wherein a —CH₂— group can optionally bereplaced by a —C(O)— or a ring sulphur atom may be optionally oxidisedto form the S-oxides; and

wherein any carbocyclyl is a saturated, partially saturated orunsaturated, mono or bicyclic carbon ring that contains 3-12 atoms,wherein a —CH₂— group can optionally be replaced by a —C(O)—;

or a pharmaceutically acceptable salt thereof.

In some embodiments, a compound of Formula IV is1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N—{(R)-1′-phenyl-1′-[N′-(carboxymethyl)carbamoyl]methyl}carbamoylmethoxy)-2,3,4,5-tetrahydro-1,5-benzothiazepine;1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N—{(R)-α-[N′—((S)-1-carboxypropyl)carbamoyl]-4-hydroxybenzyl}carbamoylmethoxy)-2,3,4,5-tetrahydro-1,5-benzothiazepine;1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N—{(R)-1′-phenyl-1′-[N′-(carboxymethyl)carbamoyl]methyl}carbamoylmethoxy)-2,3,4,5-tetrahydro-1,5-benzothiazepine;1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N—{(R)-α-[N′—((S)-1-carboxyethyl)carbamoyl]benzyl}carbamoylmethoxy)-2,3,4,5-tetrahydro-1,5-benzothiazepine; or a saltthereof.

In some embodiments, any compound described herein is covalentlyconjugated to a bile acid using any suitable method. In someembodiments, compounds described herein are covalently bonded to acyclodextrin or a biodegradable polymer (e.g., a polysaccharide).

In certain embodiments compounds described herein are not systemicallyabsorbed. Moreover, provided herein are compounds that inhibit bile saltrecycling in the gastrointestinal tract of an individual. In someembodiments, compounds described herein, may not be transported from thegut lumen and/or do not interact with ASBT. In some embodiments,compounds described herein, do not affect, or minimally affect, fatdigestion and/or absorption. In certain embodiments, the administrationof a therapeutically effective amount of any compound described hereindoes not result in gastrointestinal disturbance or lactic acidosis in anindividual. In certain embodiments, compounds described herein areadministered orally. In some embodiments, an ASBTI is released in thedistal ileum. An ASBTI compatible with the methods described herein maybe a direct inhibitor, an allosteric inhibitor, or a partial inhibitorof the Apical Sodium-dependent Bile acid Transporter.

In certain embodiments, compounds that inhibit ASBT or any recuperativebile acid transporters are compounds that are described in EP1810689,U.S. Pat. Nos. 6,458,851, 7,413,536, 7,514,421, US Appl. PublicationNos. 2002/0147184, 2003/0119809, 2003/0149010, 2004/0014806,2004/0092500, 2004/0180861, 2004/0180860, 2005/0031651, 2006/0069080,2006/0199797, 2006/0241121, 2007/0065428, 2007/0066644, 2007/0161578,2007/0197628, 2007/0203183, 2007/0254952, 2008/0070888, 2008/0070892,2008/0070889, 2008/0070984, 2008/0089858, 2008/0096921, 2008/0161400,2008/0167356, 2008/0194598, 2008/0255202, 2008/0261990, WO 2002/50027,WO2005/046797, WO2006/017257, WO2006/105913, WO2006/105912,WO2006/116499, WO2006/117076, WO2006/121861, WO2006/122186,WO2006/124713, WO2007/050628, WO2007/101531, WO2007/134862,WO2007/140934, WO2007/140894, WO2008/028590, WO2008/033431,WO2008/033464, WO2008/031501, WO2008/031500, WO2008/033465,WO2008/034534, WO2008/039829, WO2008/064788, WO2008/064789,WO2008/088836, WO2008/104306, WO2008/124505, and WO2008/130616; thecompounds described therein that inhibit recuperative bile acidtransport are hereby incorporated herein by reference.

In certain embodiments, compounds that inhibit ASBT or any recuperativebile acid transporters are compounds described in WO93/16055,WO94/18183, WO94/18184, WO96/05188, WO96/08484, WO96/16051, WO97/33882,WO98/38182, WO99/35135, WO98/40375, WO99/64409, WO99/64410, WO00/01687,WO00/47568, WO00/61568, DE 19825804, WO00/38725, WO00/38726, WO00/38727(including those compounds with a 2,3,4,5-tetrahydro-1-benzothiepine1,1-dioxide structure), WO00/38728, WO01/66533, WO02/50051, EP0864582(e.g.(3R,5R)-3-butyl-3-ethyl-1,1-dioxido-5-Phenyl-2,3,4,5-tetrahydro-1,4-benzo-thiazepin-8-yl(0-D-glucopyranosiduronic acid, WO94/24087, WO98/07749, WO98/56757,WO99/32478, WO99/35135, WO00/20392, WO00/20393, WO00/20410, WO00/20437,WO01/34570, WO00/35889, WO01/68637, WO01/68096, WO02/08211, WO03/020710,WO03/022825, WO03/022830, WO03/0222861, JP10072371, U.S. Pat. Nos.5,910,494; 5,723,458; 5,817,652; 5,663,165; 5,998,400; 6,465,451,5,994,391; 6,107,494; 6,387,924; 6,784,201; 6,875,877; 6,740,663;6,852,753; 5,070,103, 6,114,322, 6,020,330, 7,179,792, EP251315,EP417725, EP489-423, EP549967, EP573848, EP624593, EP624594, EP624595,EP869121, EP1070703, WO04/005247, compounds disclosed as having IBATactivity in Drugs of the Future, 24, 425-430 (1999), Journal ofMedicinal Chemistry, 48, 5837-5852, (2005) and Current MedicinalChemistry, 13, 997-1016, (2006); the compounds described therein thatinhibit recuperative bile acid transport are hereby incorporated hereinby reference.

In some embodiments, compounds that inhibit ASBT or any recuperativebile acid transporter are benzothiepines, benzothiazepines (including1,2-benzothiazepines; 1,4-benzothiazepines; 1,5-benzothiazepines; and/or1,2,5-benzothiadiazepines). In some embodiments, compounds that inhibitASBT or any recuperative bile acid transporter include and are notlimited to S-8921 (disclosed in EP597107, WO 93/08155), 264W94 (GSK)disclosed in WO 96/05188; SC-435(1-[4-[4-[(4R,5R)-3,3-dibutyl-7-(dimethylamino)-2,3,4,5-tetrahydro-4-hydroxy-1,1-dioxido-1-benzothiepin-5-yl]phenoxy]butyl]4-aza-1-azoniabicyclo[2.2.2]octanemethanesulfonate salt), SC-635 (Searle); 2164U90(3-butyl-3-ethyl-2,3,4,5-tetrahydro-5-phenyl-1,4-benzothiazepine1,1-dioxide); BARI-1741 (Aventis SA), AZD 7508 (Astra Zeneca); barixibat(11-(D-gluconamido)-N-{2-[(1S,2R,3S)-3-hydroxy-3-phenyl-2-(2-pyridyl)-1-(2-pyridylamino)propyl]phenyl}undecanamide)or the like, or combinations thereof. In some embodiments, an ASBTI is:

In certain embodiments, compounds described herein have one or morechiral centers. As such, all stereoisomers are envisioned herein. Invarious embodiments, compounds described herein are present in opticallyactive or racemic forms. It is to be understood that the compounds ofthe present invention encompass racemic, optically-active, regioisomericand stereoisomeric forms, or combinations thereof that possess thetherapeutically useful properties described herein. Preparation ofoptically active forms is achieved in any suitable manner, including byway of non-limiting example, by resolution of the racemic form byrecrystallization techniques, by synthesis from optically-activestarting materials, by chiral synthesis, or by chromatographicseparation using a chiral stationary phase. In some embodiments,mixtures of one or more isomer is utilized as the therapeutic compounddescribed herein. In certain embodiments, compounds described hereincontains one or more chiral centers. These compounds are prepared by anymeans, including enantioselective synthesis and/or separation of amixture of enantiomers and/or diastereomers. Resolution of compounds andisomers thereof is achieved by any means including, by way ofnon-limiting example, chemical processes, enzymatic processes,fractional crystallization, distillation, chromatography, and the like.

In some embodiments, the ASBTI is

or an alternative pharmaceutically acceptable salt thereof.

In some embodiments, the ASBTI is

or a pharmaceutically acceptable salt thereof.

In some embodiments, the ASBTI is

or an alternative pharmaceutically acceptable salt thereof.

In various embodiments the ASBTI is

or a pharmaceutically acceptable salt thereof.

In some embodiments, the ASBTI is

or a pharmaceutically acceptable salt thereof.

In some embodiments, the ASBTI is

or a pharmaceutically acceptable salt thereof.

In some embodiments, ASBTIs described herein are synthesized asdescribed in, for example, WO 96/05188, U.S. Pat. Nos. 5,994,391;7,238,684; 6,906,058; 6,020,330; and 6,114,322.

In some embodiments, the ASBTI used in the methods or compositions ofthe present invention is maralixibat (SHP625), volixibat (SHP626), orodevixibat (A4250), or a pharmaceutically acceptable salt thereof.

In some embodiments, the ASBTI used in the methods or compositions ofthe present invention is maralixibat, or a pharmaceutically acceptablesalt thereof.

In some embodiments, the ASBTI used in the methods or compositions ofthe present invention is volixibat, or a pharmaceutically acceptablesalt thereof.

In some embodiments, the ASBTI used in the methods or compositions ofthe present invention is odevixibat, or a pharmaceutically acceptablesalt thereof.

In some embodiments, the ASBTI used in the methods or compositions ofthe present invention is elobixibat, or a pharmaceutically acceptablesalt thereof.

In some embodiments, the ASBTI used in the methods or compositions ofthe present invention is GSK2330672, or a pharmaceutically acceptablesalt thereof.

In some embodiments, the ASBTI may comprise a mixture of differentASBTIs; for example, the ASBTI may be a composition comprisingmaralixibat, volixibat, odevixibat, GSK2330672, elobixibat, or variouscombinations thereof.

Methods

Provided herein is a method for treating or ameliorating cholestaticliver disease in a patient in need thereof, wherein the patient has aBSEP deficiency. The method comprises administering to the patient anApical Sodium-dependent Bile Acid Transport Inhibitor (ASBTI).

In certain embodiments, the cholestatic liver disease is progressivefamilial intrahepatic cholestasis (PFIC), PFIC type 1, PFIC type 2, PFICtype 3, Alagille syndrome, Dubin-Johnson Syndrome, biliary atresia,post-Kasai biliary atresia, post-liver transplantation biliary atresia,post-liver transplantation cholestasis, post-liver transplantationassociated liver disease, intestinal failure associated liver disease,bile acid mediated liver injury, pediatric primary sclerosingcholangitis, MRP2 deficiency syndrome, neonatal sclerosing cholangitis,a pediatric obstructive cholestasis, a pediatric non-obstructivecholestasis, a pediatric extrahepatic cholestasis, a pediatricintrahepatic cholestasis, a pediatric primary intrahepatic cholestasis,a pediatric secondary intrahepatic cholestasis, benign recurrentintrahepatic cholestasis (BRIC), BRIP type 1, BRIC type 2, BRIC type 3,total parenteral nutrition associated cholestasis, paraneoplasticcholestasis, Stauffer syndrome, drug-associated cholestasis,infection-associated cholestasis, or gallstone disease. In someembodiments, the cholestatic liver disease is a pediatric form of liverdisease.

In certain embodiments, a cholestatic liver disease is characterized byone or more symptoms selected from jaundice, pruritis, cirrhosis,hypercholemia, neonatal respiratory distress syndrome, lung pneumonia,increased serum concentration of bile acids, increased hepaticconcentration of bile acids, increased serum concentration of bilirubin,hepatocellular injury, liver scarring, liver failure, hepatomegaly,xanthomas, malabsorption, splenomegaly, diarrhea, pancreatitis,hepatocellular necrosis, giant cell formation, hepatocellular carcinoma,gastrointestinal bleeding, portal hypertension, hearing loss, fatigue,loss of appetite, anorexia, peculiar smell, dark urine, light stools,steatorrhea, failure to thrive, and/or renal failure.

In some embodiments the patient has biliary atresia.

In some embodiments, the patient has intrahepatic cholestasis ofpregnancy (ICP).

In certain embodiments, methods of the present invention comprisenon-systemic administration of a therapeutically effective amount of anASBTI. In certain embodiments, the methods comprise contacting thegastrointestinal tract, including the distal ileum and/or the colonand/or the rectum, of an individual in need thereof with an ASBTI. Invarious embodiments, the methods of the present invention cause areduction in intraenterocyte bile acids, or a reduction in damage tohepatocellular or intestinal architecture caused by cholestasis or acholestatic liver disease.

In various embodiments, methods of the present invention comprisedelivering to ileum or colon of the individual a therapeuticallyeffective amount of any ASBTI described herein.

In various embodiments the subject has a condition associated with,caused by or caused in part by a BSEP deficiency. In certainembodiments, the condition associated with, caused by or caused in partby the BSEP deficiency is neonatal hepatitis, primary biliary cirrhosis(PBC), primary sclerosing cholangitis (PSC), PFIC 2, benign recurrentintrahepatic cholestasis (BRIC), intrahepatic cholestasis of pregnancy(ICP), drug-induced cholestasis, oral-contraceptive-induced cholestasis,biliary atresia, or a combination thereof.

In various embodiments, methods of the present invention comprisereducing damage to hepatocellular or intestinal architecture or cellsfrom cholestasis or a cholestatic liver disease comprisingadministration of a therapeutically effective amount of an ASBTI. Incertain embodiments, the methods of the present invention comprisereducing intraenterocyte bile acids/salts through administration of atherapeutically effective amount of an ASBTI to an individual in needthereof.

In some embodiments, methods of the present invention provide forinhibition of bile salt recycling upon administration of any of thecompounds described herein to an individual. In some embodiments, anASBTI described herein is systemically absorbed upon administration. Insome embodiments, an ASBTI described herein is not absorbedsystemically. In some embodiments, an ASBTI herein is administered tothe individual orally. In some embodiments, an ASBTI described herein isdelivered and/or released in the distal ileum of an individual.

In various embodiments, contacting the distal ileum of an individualwith an ASBTI (e.g., any ASBTI described herein) inhibits bile acidreuptake and increases the concentration of bile acids/salts in thevicinity of L-cells in the distal ileum and/or colon and/or rectum,thereby reducing intraenterocyte bile acids, reducing serum and/orhepatic bile acid levels, reducing overall serum bile acid load, and/orreducing damage to ileal architecture caused by cholestasis or acholestatic liver disease. Without being limited to any particulartheory, reducing serum and/or hepatic bile acid levels ameliorateshypercholemia and/or cholestatic disease.

Administration of a compound described herein may be achieved in anysuitable manner including, by way of non-limiting example, by oral,enteric, parenteral (e.g., intravenous, subcutaneous, intramuscular),intranasal, buccal, topical, rectal, or transdermal administrationroutes. Any compound or composition described herein may be administeredin a method or formulation appropriate to treat a newborn or an infant.Any compound or composition described herein may be administered in anoral formulation (e.g., solid or liquid) to treat a newborn or aninfant. Any compound or composition described herein may be administeredprior to ingestion of food, with food or after ingestion of food.

In certain embodiments, a compound or a composition comprising acompound described herein is administered for prophylactic and/ortherapeutic treatments. In therapeutic applications, the compositionsare administered to an individual already suffering from a disease orcondition, in an amount sufficient to cure or at least partially arrestthe symptoms of the disease or condition. In various instances, amountseffective for this use depend on the severity and course of the diseaseor condition, previous therapy, the individual's health status, weight,and response to the drugs, and the judgment of the treating physician.

In prophylactic applications, compounds or compositions containingcompounds described herein may be administered to an individualsusceptible to or otherwise at risk of a particular disease, disorder orcondition. In certain embodiments of this use, the precise amounts ofcompound administered depend on the individual's state of health,weight, and the like. Furthermore, in some instances, when a compound orcomposition described herein is administered to an individual, effectiveamounts for this use depend on the severity and course of the disease,disorder or condition, previous therapy, the individual's health statusand response to the drugs, and the judgment of the treating physician.

In certain embodiments of the methods of the present invention, whereinfollowing administration of a selected dose of a compound or compositiondescribed herein, an individual's condition does not improve, upon thedoctor's discretion the administration of a compound or compositiondescribed herein is optionally administered chronically, that is, for anextended period of time, including throughout the duration of theindividual's life in order to ameliorate or otherwise control or limitthe symptoms of the individual's disorder, disease or condition.

In certain embodiments of the methods of the present invention, aneffective amount of a given agent varies depending upon one or more of anumber of factors such as the particular compound, disease or conditionand its severity, the identity (e.g., weight) of the subject or host inneed of treatment, and is determined according to the particularcircumstances surrounding the case, including, e.g., the specific agentbeing administered, the route of administration, the condition beingtreated, and the subject or host being treated. In some embodiments,doses administered include those up to the maximum tolerable dose. Insome embodiments, doses administered include those up to the maximumtolerable dose by a newborn or an infant.

In various embodiments of the methods of the present invention, adesired dose is conveniently presented in a single dose or in divideddoses administered simultaneously (or over a short period of time) or atappropriate intervals, for example as two, three, four or more sub-dosesper day. In various embodiments, a single dose of an ASBTI isadministered every 6 hours, every 12 hours, every 24 hours, every 48hours, every 72 hours, every 96 hours, every 5 days, every 6 days, oronce a week. In some embodiments the total single dose of an ASBTI is ina range described below.

In various embodiments of methods of the present invention, in the casewherein the patient's status does improve, upon the doctor's discretionan ASBTI is optionally given continuously; alternatively, the dose ofdrug being administered is temporarily reduced or temporarily suspendedfor a certain length of time (i.e., a “drug holiday”). The length of thedrug holiday optionally varies between 2 days and 1 year, including byway of example only, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 10days, 12 days, 15 days, 20 days, 28 days, 35 days, 50 days, 70 days, 100days, 120 days, 150 days, 180 days, 200 days, 250 days, 280 days, 300days, 320 days, 350 days, or 365 days. The dose reduction during a drugholiday includes from 10%-100% of the original dose, including, by wayof example only, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%,65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% of the original dose. In someembodiments the total single dose of an ASBTI is in a range describedbelow.

Once improvement of the patient's conditions has occurred, a maintenancedose is administered if necessary. Subsequently, the dosage or thefrequency of administration, or both, is reduced, as a function of thesymptoms, to a level at which the improved disease, disorder orcondition is retained. In some embodiments, patients requireintermittent treatment on a long-term basis upon any recurrence ofsymptoms.

In certain instances, there are a large number of variables in regard toan individual treatment regime, and considerable excursions from theserecommended values are considered within the scope described herein.Dosages described herein are optionally altered depending on a number ofvariables such as, by way of non-limiting example, the activity of thecompound used, the disease or condition to be treated, the mode ofadministration, the requirements of the individual subject, the severityof the disease or condition being treated, and the judgment of thepractitioner.

Toxicity and therapeutic efficacy of such therapeutic regimens areoptionally determined by pharmaceutical procedures in cell cultures orexperimental animals, including, but not limited to, the determinationof the LD₅₀ (the dose lethal to 50% of the population) and the ED₅₀ (thedose therapeutically effective in 50% of the population). The dose ratiobetween the toxic and therapeutic effects is the therapeutic index andit can be expressed as the ratio between LD₅₀ and ED₅₀. Compoundsexhibiting high therapeutic indices are prefer ed. In certainembodiments, data obtained from cell culture assays and animal studiesare used in formulating a range of dosage for use in human. In specificembodiments, the dosage of compounds described herein lies within arange of circulating concentrations that include the ED₅₀ with minimaltoxicity. The dosage optionally varies within this range depending uponthe dosage form employed and the route of administration utilized.

In certain embodiments, the composition used or administered comprisesan absorption inhibitor, a carrier, and one or more of a cholesterolabsorption inhibitor, an enteroendocrine peptide, a peptidase inhibitor,a spreading agent, and a wetting agent.

In some embodiments of methods of the present invention, the compositionused to prepare an oral dosage form or administered orally comprises anabsorption inhibitor, an orally suitable carrier, an optionalcholesterol absorption inhibitor, an optional enteroendocrine peptide,an optional peptidase inhibitor, an optional spreading agent, and anoptional wetting agent. In certain embodiments, the orally administeredcompositions evoke an anorectal response. In specific embodiments, theanorectal response is an increase in secretion of one or moreenteroendocrine by cells in the colon and/or rectum (e.g., in L-cellsthe epithelial layer of the colon, ileum, rectum, or a combinationthereof). In some embodiments, the anorectal response persists for atleast 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19,20, 21, 22, 23 or 24 hours. In other embodiments the anorectal responsepersists for a period between 24 hours and 48 hours, while in otherembodiments the anorectal response persists for persists for a periodgreater than 48 hours.

Genotyping

In various embodiments, the BSEP deficiency is progressive familialintrahepatic cholestasis (PFIC 2), benign recurrent intrahepaticcholestasis, or intrahepatic cholestasis of pregnancy. In variousembodiments the patient has residual BSEP function. In variousembodiments, the patient has at least about 95%, 90%, 85%, 80%, 75%,70%, 65%, 60%, 55%, 50%, 45%, 40%, 35%, 30%, 25%, 20%, 25%, 20%, 5%,2.5%, or T % BSEP function relative to a healthy individual without anycholestatic liver disease. In various embodiments, the patent has amaximum of about 99%, 95%, 95%, 90%, 85%, 80%, 75%, 70%, 65%, 60%, 55%,50%, 45%, 40%, 35%, 30%, 25%, 20%, 25%, 20%, 5%, or 2.5% BSEP functionrelative to a healthy individual without any cholestatic liver disease.The BSEP deficiency can result in impaired or reduced bile flow orcholestasis.

In various embodiments, the BSEP deficiency is caused by a mutation inan ABCB11 gene. In various embodiments, the mutation in the ABCB11 geneis a non-truncating mutation. In general, truncating mutations to theABCB11 gene can result in lack of residual function of the encoded BSEP(“severe” mutation). In various embodiments, the ABCB11 gene includes amutation and does not comprise any truncating mutations. The ABCB11 genemutation can be a missense or nonsense mutation, an insertion, or adeletion. In some embodiments, the ABCB11 gene includes an E297G or aD482G mutation, alternatively referred to as “mild” mutations or “mildPFIC 2.” In some embodiments, the ABCB11 gene comprises a missensemutation and does not include an E297G or a D482G missense mutation,alternatively referred to as “moderate” mutations or “moderate PFIC 2.”The ABCB11 gene can include an E297G, D482G, alternative missensemutations, insertions, deletions, and various combinations thereof. Invarious embodiments, the alternative missense mutation may be selectedfrom one of those mutations listed in Byrne, et al., “Missense Mutationsand Single Nucleotide Polymorphisms in ABCB11 Impair Bile Salt ExportPump Processing and Function or Disrupt Pre-Messanger RNA Splicing,”Hepatology, 49:553-567 (2009), which is incorporated herein by referencein its entirety for all purposes.

In various embodiments, the patient has total loss of BSEP activity. Invarious embodiments, the patient having total loss of BSEP activity ishomozygous for ABCB11 genes having mutations resulting in total loss ofencoded BSEP activity (e.g., truncating or frame-shift mutations). Invarious embodiments, the patient has residual BSEP activity. In variousembodiments, the patient having residual BSEP activity is heterozygousfor an ABCB11 gene having mutations resulting in total loss of encodedBSEP activity (e.g., patients having an ABCB11 gene with a truncatingmutation and a wild type ABCB11 gene or patients having an ABCB11 genewith a truncating mutation and ABCB11 gene having mutations encodingBSEP having residual activity but activity that is reduced relative towild type BSEP). In certain embodiments, the patient having residualBSEP activity is homozygous for ABCB11 genes having mutations resultingin residual BSEP activity and reduced activity of BSEP relative to wildtype (e.g., patients having ABCB11 genes with the same or differentmissense mutation(s)). In some embodiments, the patient having residualBSEP activity is heterozygous for ABCB11 genes having mutationsresulting in residual BSEP activity and reduced activity of BSEPrelative to wild type (e.g., patients having a wild type ABCB11 gene andan ABCB11 gene having a missense mutation).

In various embodiments, the method includes determining a genotype ofthe patient. Determining the genotype can include any of various methodsknown in the art for determining a gene sequence for the patient,including as non-limiting examples restriction fragment lengthpolymorphism identification of genomic DNA, random amplified polymorphicdetection of genomic DNA, amplified fragment length polymorphismdetection, polymerase chain reaction, DNA sequencing, allele specificoligonucleotide probes, hybridization to DNA microarrays or beads, andvarious combinations thereof. In various embodiments, determining thegenotype includes determining a sequence of the ABCB11 gene.

In some embodiments, the method includes determining the genotypeincludes identifying and characterizing a mutation in the ABCB11 gene.Determining the genotype can include determining a sequence for aportion or an entirety of the ABCB11 gene. Determining the genotype canfurther include determining a sequence for a genomic region surroundingthe ABCB11 gene or determining a sequence for one or more introns and/orexons of the ABCB11 gene. Determining the genotype can includecharacterizing the ABCB11 gene by identifying one, multiple, or allmutations of ABCB11 gene-encoding alleles of the patient. In variousembodiments, determining the genotype includes determining whether ornot the ABCB11 gene has a truncating mutation, an insertion, a deletion,a missense mutation, the E297G mutation, the D482G mutation, a splicesite mutation, a nonsense mutation, a frameshift mutation, or variouscombinations thereof.

Dosages

In various embodiments, the patient is a pediatric patient under the ageof 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, or 18years old. In certain embodiments, the pediatric patient is a newborn, apre-term newborn, an infant, a toddler, a preschooler, a school-agechild, a pre-pubescent child, post-pubescent child, an adolescent, or ateenager under the age of eighteen. In some embodiments, the pediatricpatient is a newborn, a pre-term newborn, an infant, a toddler, apreschooler, or a school-age child. In some embodiments, the pediatricpatient is a newborn, a pre-term newborn, an infant, a toddler, or apreschooler. In some embodiments, the pediatric patient is a newborn, apre-term newborn, an infant, or a toddler. In some embodiments, thepediatric patient is a newborn, a pre-term newborn, or an infant. Insome embodiments, the pediatric patient is a newborn. In someembodiments, the pediatric patient is an infant. In some embodiments,the pediatric patient is a toddler.

In some embodiments, the patient is an adult over the age of 18, 20, 30,40, 50, 60, or 70.

In various embodiments the ASBTI is maralixibat, volixibat, odevixibat,or a pharmaceutically acceptable salt thereof.

In various embodiments, efficacy and safety of ASBTI administration tothe patient is monitored by measuring serum levels of7α-hydroxy-4-cholesten-3-one (7αC4), sBA concentration, a ratio of 7αC4to sBA (7αC4:sBA), serum bilirubin concentration, serum ALTconcentration, serum AST concentration, or a combination thereof. Invarious embodiments, efficacy of ASBTI administration is measured bymonitoring observer-reported itch reported outcome (ITCHRO(OBS)) score,a HRQoL (e.g., PedsQL) score, a CSS score, a height Z-score, a weightZ-score, or various combinations thereof. In various embodiments, themethod includes monitoring serum levels of 7α-hydroxy-4-cholesten-3-one(7αC4), sBA concentration, a ratio of 7αC4 to sBA (7αC4:sBA), serumbilirubin concentration, serum ALT concentration, serum ASTconcentration, or a combination thereof. In various embodiments, themethod includes monitoring observer-reported itch reported outcome(ITCHRO(OBS)) score, a HRQoL (e.g., PedsQL) score, a CSS score, a heightZ-score, a weight Z-score or various combinations thereof.

In some embodiments, the ASBTI is administered at a dose of about or atleast about 0.5 μg/kg, 1 μg/kg, 2 μg/kg, 3 μg/kg, 4 μg/kg, 5 μg/kg, 6μg/kg, 7 μg/kg, 8 μg/kg, 9 μg/kg, 10 μg/kg, 15 μg/kg, 20 μg/kg, 25μg/kg, 30 μg/kg, 35 μg/kg, 40 μg/kg, 45 μg/kg, 50 μg/kg, 55 μg/kg, 60μg/kg, 65 μg/kg, 70 μg/kg, 75 μg/kg, 80 μg/kg, 85 μg/kg, 90 μg/kg, 100μg/kg, 140 μg/kg, 150 μg/kg, 200 μg/kg, 240 μg/kg, 280 μg/kg, 300 μg/kg,250 μg/kg, 280 μg/kg, 300 μg/kg, 400 μg/kg, 500 μg/kg, 560 μg/kg, 600μg/kg, 700 μg/kg, 800 μg/kg, 900 μg/kg, 1,000 μg/kg, 1,100 μg/kg, 1,200μg/kg, 1,300 μg/kg, 1,400 μg/kg, 1500 μg/kg, 1,600 μg/kg, 1,700 μg/kg,1,800 μg/kg, 1,900 μg/kg, or 2,000 μg/kg. In various embodiments, theASBTI is administered at a dose not exceeding about 1 μg/kg, 2 μg/kg, 3μg/kg, 4 μg/kg, 5 μg/kg, 6 μg/kg, 7 μg/kg, 8 μg/kg, 9 μg/kg, 10 μg/kg,15 μg/kg, 20 μg/kg, 25 μg/kg, 30 μg/kg, 35 μg/kg, 40 μg/kg, 45 μg/kg, 50μg/kg, 55 μg/kg, 60 μg/kg, 65 μg/kg, 70 μg/kg, 75 μg/kg, 80 μg/kg, 85μg/kg, 90 μg/kg, 100 μg/kg, 140 μg/kg, 150 μg/kg, 200 μg/kg, 240 μg/kg,280 μg/kg, 300 μg/kg, 250 μg/kg, 280 μg/kg, 300 μg/kg, 400 μg/kg, 500μg/kg, 560 μg/kg, 600 μg/kg, 700 μg/kg, 800 μg/kg, 900 μg/kg, 1,000μg/kg, 1,100 μg/kg, 1,200 μg/kg, 1,300 μg/kg, 1,400 μg/kg, 1,500 μg/kg,1,600 μg/kg, 1,700 μg/kg, 1,800 μg/kg, 1,900 μg/kg, 2,000, or 2,100μg/kg. In various embodiments, the ASBTI is administered at a dose ofabout or of at least about 0.5 mg/day, 1 mg/day, 2 mg/day, 3 mg/day, 4mg/day, 5 mg/day, 6 mg/day, 7 mg/day, 8 mg/day, 9 mg/day, 10 mg/day, 11mg/day, 12 mg/day, 13 mg/day, 14 mg/day, 15 mg/day, 16 mg/day, 17mg/day, 18 mg/day, 19 mg/day, 20 mg/day, 30 mg/day, 40 mg/day, 50mg/day, 60 mg/day, 70 mg/day, 80 mg/day, 90 mg/day, 100 mg/day, 150mg/day, 200 mg/day, 300 mg/day, 500 mg/day, 600 mg/day, 700 mg/day, 800mg/day, 900 mg/day, 1000 mg/day. In various embodiments, the ASBTI isadministered at a dose of not more than about 1 mg/day, 2 mg/day, 3mg/day, 4 mg/day, 5 mg/day, 6 mg/day, 7 mg/day, 8 mg/day, 9 mg/day, 10mg/day, 11 mg/day, 12 mg/day, 13 mg/day, 14 mg/day, 15 mg/day, 16mg/day, 17 mg/day, 18 mg/day, 19 mg/day, 20 mg/day, 30 mg/day, 40mg/day, 50 mg/day, 60 mg/day, 70 mg/day, 80 mg/day, 90 mg/day, 100mg/day, 150 mg/day, 200 mg/day, 300 mg/day, 500 mg/day, 600 mg/day, 700mg/day, 800 mg/day, 900 mg/day, 1,000 mg/day, 1,100 mg/day.

In some embodiments, the ASBTI is administered at a dose of from about140 μg/kg/day to about 1400 μg/kg/day. In various embodiments, the ASBTIis administered at a dose of about or at least about 0.5 μg/kg/day, 1μg/kg/day, 2 μg/kg/day, 3 μg/kg/day, 4 μg/kg/day, 5 μg/kg/day, 6μg/kg/day, 7 μg/kg/day, 8 μg/kg/day, 9 μg/kg/day 10 μg/kg/day, 15μg/kg/day, 20 μg/kg/day, 25 μg/kg/day, 30 μg/kg/day, 35 μg/kg/day, 40μg/kg/day, 45 μg/kg/day, 50 μg/kg/day, 100 μg/kg/day, 140 μg/kg/day, 150μg/kg/day, 200 μg/kg/day, 240 μg/kg/day, 280 μg/kg/day, 300 μg/kg/day,250 μg/kg/day, 280 μg/kg/day, 300 μg/kg/day, 400 μg/kg/day, 500μg/kg/day, 560 μg/kg/day, 600 μg/kg/day, 700 μg/kg/day, 800 μg/kg/day,900 μg/kg/day, 1,000 μg/kg/day, 1,100 μg/kg/day, 1,200 μg/kg/day, or1,300 μg/kg/day. In various embodiments, the ASBTI is administered at adose not exceeding about 1 μg/kg/day, 2 μg/kg/day, 3 μg/kg/day, 4μg/kg/day, 5 μg/kg/day, 6 μg/kg/day, 7 μg/kg/day, 8 μg/kg/day, 9μg/kg/day 10 μg/kg/day, 15 μg/kg/day, 20 μg/kg/day, 25 μg/kg/day, 30μg/kg/day, 35 μg/kg/day, 40 μg/kg/day, 45 μg/kg/day, 50 μg/kg/day, 100μg/kg/day, 140 μg/kg/day, 150 μg/kg/day, 200 μg/kg/day, 240 μg/kg/day,280 μg/kg/day, 300 μg/kg/day, 250 μg/kg/day, 280 μg/kg/day, 300μg/kg/day, 400 μg/kg/day, 500 μg/kg/day, 560 μg/kg/day, 600 μg/kg/day,700 μg/kg/day, 800 μg/kg/day, 900 μg/kg/day, 1,000 μg/kg/day, 1,100μg/kg/day, 1,200 μg/kg/day, 1,300 μg/kg/day, or 1,400 μg/kg/day. Invarious embodiments, the ASBTI is administered at a dose of from about0.5 μg/kg/day to about 500 μg/kg/day, from about 0.5 μg/kg/day to about250 μg/kg/day, from about 1 μg/kg/day to about 100 μg/kg/day, from about10 μg/kg/day to about 50 μg/kg/day, from about 10 μg/kg/day to about 100μg/kg/day, from about 0.5 μg/kg/day to about 2000 μg/kg/day, from about280 μg/kg/day to about 1400 μg/kg/day, from about 420 μg/kg/day to about1400 μg/kg/day, from about 250 to about 550 μg/kg/day, from about 560μg/kg/day to about 1400 μg/kg/day, from 700 μg/kg/day to about 1400μg/kg/day, from about 560 μg/kg/day to about 1200 μg/kg/day, from about700 μg/kg/day to about 1200 μg/kg/day, from about 560 μg/kg/day to about1000 μg/kg/day, from about 700 μg/kg/day to about 1000 μg/kg/day, fromabout 800 μg/kg/day to about 1000 μg/kg/day, from about 200 μg/kg/day toabout 600 μg/kg/day, from about 300 μg/kg/day to about 600 μg/kg/day,from about 400 μg/kg/day to about 500 μg/kg/day, from about 400μg/kg/day to about 600 μg/kg/day, from about 400 μg/kg/day to about 700μg/kg/day, from about 400 μg/kg/day to about 800 μg/kg/day, from about500 μg/kg/day to about 800 μg/kg/day, from about 500 μg/kg/day to about900 μg/kg/day, from about 600 μg/kg/day to about 900 μg/kg/day, fromabout 700 μg/kg/day to about 900 μg/kg/day, from about 200 μg/kg/day toabout 600 μg/kg/day, from about 800 μg/kg/day to about 900 μg/kg/day,from about 100 μg/kg/day to about 1500 μg/kg/day, from about 300μg/kg/day to about 2,000 μg/kg/day, or from about 400 μg/kg/day to about2000 μg/kg/day.

In some embodiments, the ASBTI is administered at a dose of from about30 μg/kg to about 1400 μg/kg per dose. In some embodiments, the ASBTI isadministered at a dose of from about 0.5 μg/kg to about 2000 μg/kg perdose, from about 0.5 μg/kg to about 1500 μg/kg per dose, from about 100μg/kg to about 700 μg/kg per dose, from about 5 μg/kg to about 100 μg/kgper dose, from about 10 μg/kg to about 500 μg/kg per dose, from about 50μg/kg to about 1400 μg/kg per dose, from about 300 μg/kg to about 2,000μg/kg per dose, from about 60 μg/kg to about 1200 μg/kg per dose, fromabout 70 μg/kg to about 1000 μg/kg per dose, from about 70 μg/kg toabout 700 μg/kg per dose, from 80 μg/kg to about 1000 μg/kg per dose,from 80 μg/kg to about 800 μg/kg per dose, from 100 μg/kg to about 800μg/kg per dose, from 100 μg/kg to about 600 μg/kg per dose, from 150μg/kg to about 700 μg/kg per dose, from 150 μg/kg to about 500 μg/kg perdose, from 200 μg/kg to about 400 μg/kg per dose, from 200 μg/kg toabout 300 μg/kg per dose, or from 300 μg/kg to about 400 μg/kg per dose.

In some embodiments, the ASBTI is administered at a dose of from about0.5 mg/day to about 550 mg/day. In various embodiments, the ASBTI isadministered at a dose of from about 1 mg/day to about 500 mg/day, fromabout 1 mg/day to about 300 mg/day, from about 1 mg/day to about 200mg/day, from about 2 mg/day to about 300 mg/day, from about 2 mg/day toabout 200 mg/day, from about 4 mg/day to about 300 mg/day, from about 4mg/day to about 200 mg/day, from about 4 mg/day to about 150 mg/day,from about 5 mg/day to about 150 mg/day, from about 5 mg/day to about100 mg/day, from about 5 mg/day to about 80 mg/day, from about 5 mg/dayto about 50 mg/day, from about 5 mg/day to about 40 mg/day, from about 5mg/day to about 30 mg/day, from about 5 mg/day to about 20 mg/day, fromabout 5 mg/day to about 15 mg/day, from about 10 mg/day to about 100mg/day, from about 10 mg/day to about 80 mg/day, from about 10 mg/day toabout 50 mg/day, from about 10 mg/day to about 40 mg/day, from about 10mg/day to about 20 mg/day, from about 20 mg/day to about 100 mg/day,from about 20 mg/day to about 80 mg/day, from about 20 mg/day to about50 mg/day, or from about 20 mg/day to about 40 mg/day, or from about 20mg/day to about 30 mg/day.

In various embodiments, the dose of the ASBTI is a first dose level. Invarious embodiments, the dose of the ASBTI is a second dose level. Insome embodiments, the second dose level is greater than the first doselevel. In some embodiments, the second dose level is about or at leastabout 1.5, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 60, 70, 80,90 or 100 times or fold greater than the first dose level. In someembodiments, the second dose level is not in excess of about 1.5, 2, 3,4, 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 60, 70, 80, 90, 100, or 150times or fold greater than the first dose level.

In various embodiments, the ASBTI is administered once daily (QD) at oneof the above doses or within one of the above dose ranges. In variousembodiments, the ASBTI is administered twice daily (BID) at one of theabove doses or within one of the above dose ranges. In variousembodiments, an ASBTI dose is administered daily, every other day, twicea week, or once a week.

In various embodiments, the ASBTI is administered regularly for a periodof about or of at least about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 30,40, 48, 50, 75, 100, 150, 200, 250, 300, 350, 400, 450, 500, 600, 700,or 800 weeks. In various embodiments, the ASBTI is administered for notmore than about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 48, 50,75, 100, 150, 200, 250, 300, 350, 400, 450, 500, 600, 700, 800, or 1000weeks. In various embodiments, the ASBTI is administered regularly for aperiod of about or of at least about 0.5, 1, 1.5, 2, 3, 4, 5, 6, 7, 8,9, or 10 years. In various embodiments, the ASBTI is administeredregularly for a period not in excess of about 0.5, 1, 1.5, 2, 3, 4, 5,6, 7, 8, 9, 10, or 15 years.

Dose Modulation

In various embodiments, the method includes modulating a dosage of theASBTI administered to the patient. The modulation includes determiningthe 7αC4:sBA ratio for the patient at a baseline (e.g., prior toadministration of the ASBTI or prior to modulating (e.g., increasing) adosage of the ASBTI), and further determining the 7αC4:sBA ratio afteradministering the ASBTI at a first dose or modulating (e.g., increasing)a dosage amount of the ASBTI to a second dose. If the 7αC4:sBA ratiodoes not increase by at least 1, 1.25, 1.5, 1.75, 2, 2.5, 3, 4, 5, 6, 7,8, 9, 10, 15, 20, 30, 40, 50, 75, 100, 150, 200, 300, 500, 750, 1,000,2,000, 3,000, 4,000, 5,000 or 10,000-fold from baseline, the dose of theASBTI is increased until the ratio increases at least about 1.25, 1.5,1.75, 2, 2.5, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 75, 100, 150,200, 300, 500, 750, 1,000, 2,000, 3,000, 4,000, 5,000 or 10,000-foldrelative to baseline. In various embodiments, the dose of the ASBTI isincreased or decreased to achieve and maintain a particular 7αC4:sBAratio.

In various embodiments, the modulating includes increasing a dose of theASBTI from a first dose level to a second dose level greater than thefirst dose level if the 7αC4:sBA ratio initially increases by at least1, 1.25, 1.5, 1.75, 2, 2.5, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50,75, 100, 150, 200, 300, 500, 750, 1,000, 2,000, 3,000, 4,000, 5,000 or10,000-fold from baseline and then begins to decrease or decreases toless than 1, 1.25, 1.5, 1.75, 2, 2.5, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20,30, 40, 50, 75, 100, 150, 200, 300, 500, 750, 1,000, 2,000, 3,000,4,000, 5,000 or 10,000-fold or greater higher than baseline. The doselevel is increased until the 7αC4:sBA ratio increases to at least 1,1.25, 1.5, 1.75, 2, 2.5, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50,75, 100, 150, 200, 300, 500, 750, 1,000, 2,000, 3,000, 4,000, 5,000 or10,000-fold from the baseline.

In some embodiments, the modulation includes administering a first doseof the ASBTI to the patient. If the 7αC4:sBA ratio does not increase orincrease by at least 1, 1.25, 1.5, 1.75, 2, 2.5, 3, 4, 5, 6, 7, 8, 9,10, 15, 20, 30, 40, 50, 75, 100, 150, 200, 300, 500, 750, 1,000, 2,000,3,000, 4,000, 5,000 or 10,000-fold from baseline, the patient is thenadministered a second dose of the ASBTI higher than the first dose. Thedose administered to the patient continues to be increased until the7αC4:sBA ratio increases by at least 1, 1.25, 1.5, 1.75, 2, 2.5, 3, 4,5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 75, 100, 150, 200, 300, 500, 750,1,000, 2,000, 3,000, 4,000, 5,000 or 10,000-fold from baseline.

In various embodiments, the 7αC4:sBA ratio is measured about daily,bi-weekly, weekly, bi-monthly, monthly, every two months, every threemonths, every four months, every five months, every six months, orannually, and the dose of the ASBTI is modulated as necessary each timethe ratio is measured.

Predicting Patient Response Based Upon Genotype

In an aspect of the invention, a prediction method is provided forpredicting patient response to treatment of a cholestatic liver disease.The treatment includes administering to the patient in need of suchtreatment an ASBTI. The method includes determining the genotype of thepatient, as described above, and predicting patient response to thetreatment based upon the genotype. In various embodiments, the patienthas a BSEP deficiency. In some embodiments, the patient has PFIC 2.

In various embodiments the prediction method includes predicting thatthe patient will not be responsive to administration of the ASBTI if theABCB11 gene comprises a truncating mutation. In some embodiments, themethod includes predicting that the patient will not be responsive toadministration of the ASBTI if the ABCB11 gene comprises a mutation thatleads to a lack of any residual BSEP activity in the patient (i.e., to atotal loss of BSEP activity). In some embodiments, the method includespredicting that the patient will not be responsive to administration ofthe ASBTI if the patient has a genotype that corresponds to total lackor loss of BSEP activity (e.g., the patient has a genome sequence thatincludes no non-truncated alleles of the ABCB11 gene). In variousembodiments, the prediction method includes predicting that the patientwill be responsive to administration of the ASBTI if the ABCB11 genecomprises mutations that result in residual BSEP activity and the ABCB11gene comprises no mutations that result in absence of BSEP activity. Oneof skill in the art will understand that if the patient has a genomeincluding at least one functional ABCB11 gene, the patient will haveresidual BSEP activity.

In some embodiments, the prediction method includes predicting that ifthe ABCB11 gene comprises the E297G mutation or the D482G mutation themethod further comprises predicting that the patient will be responsiveto administration of the ASBTI at the first daily dose. Further, if theABCB11 gene comprises an alternative missense mutation and not the E287Gor the D482G mutation, the method further includes predicting that thepatient will be responsive to administration of the ASBTI at the seconddaily dose, where the second daily dose is greater than the first dailydose. If the patient is predicted to be responsive to administration ofthe ASBTI, the method further includes administering the ASBTI to thepatient at the first daily dose or the second daily dose. In variousembodiments, the ASBTI is not administered to the patient if the patientis predicted to not respond to ASBTI treatment.

Method of Treatment Using Genotype Information

In an aspect of the invention, a method is provided for treating orameliorating cholestatic liver disease in a patient in need thereof,where the patient has a BSEP deficiency. The method includes determininga genotype of the patient, as described above. The method also includesusing the genotype of the patient to predict whether the patient will beor will not be responsive to treatment with the ASBTI, as describedabove. The method further includes administering the ASBTI to thepatient if the patient is predicted to be responsive to administrationof the ASBTI. In various embodiments, the BSEP deficiency is PFIC2.

In various embodiments, the method of the invention includes following afirst dosing regimen of the ASBTI if the ABCB11 gene comprises an E297Gor D482G mutation and following a second dosing regimen of the ASBTI ifthe ABCB11 gene comprises a missense mutation and does not comprise theE297G or the D482G mutation. In some embodiments, the first dosingregimen comprises administering a first daily dose of the ASBTI and thesecond dosing regimen comprises administering a second total daily doseof the ASBTI, where the first total daily dose is greater than thesecond total daily dose.

In various embodiments, the first dosing regimen is not equivalent tothe second dosing regimen in terms of administration frequency, dose, ora combination thereof. The first dosing regimen and the second dosingregimen may include any of the various above listed dosing frequencies,administration of any of the various above listed dosage levels to thepatient, and various combinations thereof.

Reduction in Symptoms or Change in Disease-Relevant Laboratory Measuresof Cholestatic Liver Disease

In various embodiments of the above methods of the invention,administration of the ASBTI results in a reduction in a symptom orchange in a disease-relevant laboratory measure of the cholestatic liverdisease (i.e., improvement in the patient's condition) that ismaintained for about or for at least about 1 day, 2 days, 3 days, 4days, 5 days, 6 days, 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6weeks, 7 weeks, 8 weeks, 9 weeks 10 weeks, 11 weeks, 12 weeks, 13 weeks,14 weeks, 15 weeks, 16 weeks, 17 weeks, 18 weeks, 19 weeks, 20 weeks, 21weeks, 22 weeks, 23 weeks, 24 weeks, 25 weeks, 26 weeks, 27 weeks, 28weeks, 29 weeks, 30 weeks, 31 weeks, 32 weeks, 33 weeks, 34 weeks, 35weeks, 36 weeks, 37 weeks, 38 weeks, 39 weeks, 40 weeks, 41 weeks, 42weeks, 43 weeks, 44 weeks, 45 weeks, 46 weeks, 47 weeks, 48 weeks, 49weeks, 50 weeks, 51 weeks, 52 weeks, 1 year, 13 months, 14 months, 15months, 16 months, 17 months, 18 months, 19 months, 20 months, 21months, 22 months, 23 months, 23 months, 2 years, 2.5 years, 3 years,3.5 years, 4 years, 4.5 years, 5 years, 5.5 years, 6 years, 6.5 years, 7years, 8 years, 9 years, or 10 years. In various embodiments, thereduction in the symptom or a change in a disease-relevant laboratorymeasure comprises a reduction in sBA concentration, an increase in serum7αC4 concentration, an increase in the 7αC4:sBA ratio, an increase infBA excretion, a reduction in pruritis, a reduction in ALT levels, anincrease in a quality of life inventory score, an increase in a qualityof life inventory score related to fatigue, or a combination thereof. Invarious embodiments, the reduction in the symptom or a change in adisease-relevant laboratory measure is determined relative to a baselinelevel. That is, the reduction in the symptom or a change in adisease-relevant laboratory measure is determined relative to ameasurement of the symptom or a change in a disease-relevant laboratorymeasure prior to 1) changing a dose level of the ASBTI administered tothe patient, 2) changing a dosing regimen followed for the patient, 3)commencing administration of the ASBTI, or 4) any other of variousalterations made with the intention of reducing the symptom or a changein a disease-relevant laboratory measure in the patient. In variousembodiments, the reduction in symptom or a change in a disease-relevantlaboratory measure is a statistically significant reduction.

In some embodiments, the patient is the pediatric patient and thereduction in symptom or a change in a disease-relevant laboratorymeasure comprises an increase in growth. In some embodiments, theincrease in growth is measured relative to baseline. In variousembodiments, increase in growth is measured as an increase in heightZ-score or in weight Z-score. In various embodiments, the increase inheight Z-score or in weight Z-score is statistically significant. Invarious embodiments, the height Z-score, the weight Z-score, or both isincreased by at least 0.1, 0.11, 0.12, 0.13, 0.14, 0.15, 0.16, 0.17,0.18, 0.19, 0.2, 0.21, 0.22, 0.23, 0.24, 0.25, 0.26, 0.27, 0.28, 0.290.3, 0.31, 0.32, 0.33, 0.34, 0.35, 0.36, 0.37, 0.38, 0.39 0.4, 0.41,0.42, 0.43, 0.44, 0.45, 0.46, 0.47, 0.48, 0.49, 0.5, 0.51, 0.52, 0.53,0.54, 0.55, 0.56, 0.57, 0.58, 0.59, 0.6, 0.7, 0.8, or 0.9 relative tobaseline. In some embodiments, the height Z-score, the weight Z-score,or both progressively increases during administration of the ASBTI for aperiod of about or of at least about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 20,30, 40, 48, 50, 60, 70, or 72 weeks.

In various embodiments, the administration of the ASBTI results in anincrease in serum 7αC4 concentration. In various embodiments, the serum7αC4 concentration is increased by about or at least about 1.5, 2, 3, 4,5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 60, 70, 80, 90, 100, 200, 300,400, or 500 times or fold relative to baseline. In various embodimentsthe serum 7αC4 concentration is increased about or at least about 10%,20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%, 150%, 200%, 300%, 400%,500%, 600%, 700%, 800%, 900%, 1,000%, or 10,000% relative to baseline.

In various embodiments, the administration of the ASBTI results in anincrease in the 7αC4:sBA ratio to about or by at least about 1, 1.25,1.5, 1.75, 2, 2.5, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 75, 100,150, 200, 300, 500, 750, 1,000, 2,000, 3,000, 4,000, 5,000 or10,000-fold relative to baseline.

In various embodiments, the administration of the ASBTI results in anincrease in fBA excretion. In some embodiments, the administration ofthe ASBTI results in an increase in fBA excretion of about or of atleast about 100%, 110%, 115%, 120%, 130%, 150%, 200%, 250%, 275%, 300%,400%, 500%, 600%, 700%, 800%, 1,000%, 5,000%, 10,000% or 15,000%relative to baseline. In various embodiments, fBA excretion is increasedby about or by at least about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 20, 30, 40,50, 60, 70, 80, 90, or 100 fold or times relative to baseline. In someembodiments, fBA excretion is increased by about or by at least about100 μmol, 150 μmol, 200 μmol, 250 μmol, 300 μmol, 400 μmol, 500 μmol,600 μmol, 700 μmol, 800 μmol, 900 μmol, 1,000 μmol, or 1,500 μmolrelative to baseline. In various embodiments, administration of theASBTI results in a dose-dependent increase in fBA excretion so thatadministration of a higher dose of the ASBTI results in a correspondinghigher level of fBA excretion. In various embodiments, the ASBTI isadministered at a dose sufficient to result in an increase in bile acidsecretion relative to baseline of at least about or of about 1, 1.5, 2,3, 4, 5, 6, 7, 8, 9, 10, 20, 30, 40, 50, 60, 70, 80, 90, or 100 fold ortimes relative to baseline.

In some embodiments, the administration of the ASBTI results in areduction in severity of pruritus. In various embodiments, the severityof pruritus is measured using an ITCHRO(OBS) score, an ITCHRO score, aCSS score, or a combination thereof. In various embodiments, theadministration of the ASBTI results in a reduction in the ITCHRO(OBS)score on a scale of 1 to 4 of about or of at least about 0.1, 0.2, 0.3,0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8,1.9, 2, 2.25, 2.5, or 3 relative to baseline. In various embodiments,the administration of the ASBTI results in a reduction in the ITCHROscore on a scale of 1 to 10 of about or of at least about 0.1, 0.2, 0.3,0.4, 0.5, 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, 7.5, 8,8.5, 9, 9.5, or 10. In various embodiments, the administration of theASBTI results in a reduction of the ITCHRO(OBS) score, the ITCHRO score,or both to zero. In various embodiments, the administration of the ASBTIresults in a reduction of the ITCHRO(OBS) score or ITCHRO score to 1.0or lower. In various embodiments, the administration of the ASBTIresults in a reduction of the CSS score by about of at least about 0.1,0.2, 0.3, 0.4, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1, 1.1, 1.2, 1.3, 1.4, 1.5,1.6, 1.7, 1.8, 1.9, 2, 2.25, 2.5, or 3 relative to baseline. In variousembodiments, the administration of the ASBTI results in a reduction ofthe CSS score to zero. In various embodiments, the administration of theASBTI results in a reduction in the CSS score, the ITCHRO(OBS) score,the ITCHRO score, or a combination thereof by about or by at least about10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%,80%, 85%, 90%, 95%, or 100% relative to baseline. In variousembodiments, a reduced value relative to baseline of the CSS score, theITCHRO(OBS) score, the ITCHRO score, or a combination thereof isobserved on 10%, 20%, 30%, 40%, 50%, 60%, 70%, 75%, 80%, 85%, 90%, 91%,92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or 100% of days.

In various embodiments, administration of the ASBTI results in anincrease in a quality of life inventory score or in a quality of lifeinventory score related to fatigue. The quality of life inventory scorecan be a health-related quality of life (HRQoL) score. In someembodiments, the HRQoL score is a PedsQL score. In various embodiments,the administration of the ASBTI results an increase in the PedsQL scoreor in a PedsQL score related to fatigue of about or of at least about5%, 10%, 15%, 20%, 25%, 30%, 45%, or 50% relative to baseline.

In various embodiments, the administration of the ASBTI results in thereduction in the symptom or a change in a disease-relevant laboratorymeasure by about 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days,8 days, 9 days, 10 days, 11 days, 12, days, 13 days, 14 days, 3 weeks, 4weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks 10 weeks, 11 weeks,12 weeks, 13 weeks, 14 weeks, 15 weeks, 16 weeks, 17 weeks, 18 weeks, 19weeks, 20 weeks, 21 weeks, 22 weeks, 23 weeks, 24 weeks, 25 weeks, 26weeks, 27 weeks, 28 weeks, 29 weeks, 30 weeks, 31 weeks, 32 weeks, 33weeks, 34 weeks, 35 weeks, 36 weeks, 37 weeks, 38 weeks, 39 weeks, 40weeks, 41 weeks, 42 weeks, 43 weeks, 44 weeks, 45 weeks, 46 weeks, 47weeks, 48 weeks, 49 weeks, 50 weeks, 51 weeks, 52 weeks, or 1 year.

In various embodiments, serum bilirubin concentration is atpre-administration baseline levels or at normal levels at about or byabout 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 1 week, 2 weeks, 3weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks 10 weeks, 11weeks, 12 weeks, 13 weeks, 14 weeks, 15 weeks, 16 weeks, 4 months, 17weeks, 18 weeks, 19 weeks, 20 weeks, 21 weeks, 22 weeks, 23 weeks, 24weeks, 25 weeks, 26 weeks, 27 weeks, 28 weeks, 29 weeks, 30 weeks, 31weeks, 32 weeks, 33 weeks, 34 weeks, 35 weeks, 36 weeks, 37 weeks, 38weeks, 39 weeks, 40 weeks, 41 weeks, 42 weeks, 43 weeks, 44 weeks, 45weeks, 46 weeks, 47 weeks, 48 weeks, 49 weeks, 50 weeks, 51 weeks, 52weeks, or 1 year.

In various embodiments, serum ALT concentration is at pre-administrationbaseline levels or at normal levels at about or by about 1 day, 2 days,3 days, 4 days, 5 days, 6 days, 1 week, 2 weeks, 3 weeks, 4 weeks, 5weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks 10 weeks, 11 weeks, 12 weeks,13 weeks, 14 weeks, 15 weeks, 16 weeks, 4 months, 17 weeks, 18 weeks, 19weeks, 20 weeks, 21 weeks, 22 weeks, 23 weeks, 24 weeks, 25 weeks, 26weeks, 27 weeks, 28 weeks, 29 weeks, 30 weeks, 31 weeks, 32 weeks, 33weeks, 34 weeks, 35 weeks, 36 weeks, 37 weeks, 38 weeks, 39 weeks, 40weeks, 41 weeks, 42 weeks, 43 weeks, 44 weeks, 45 weeks, 46 weeks, 47weeks, 48 weeks, 49 weeks, 50 weeks, 51 weeks, 52 weeks, or 1 year. Insome embodiments, the administration of the ASBTI results in a reductionin ALT levels relative to baseline of about or of at least about 1%, 2%,3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, 11%, 12%, 13%, 14%, or 15%.

In various embodiments, serum ALT concentration, serum ASTconcentration, serum bilirubin concentration, or various combinationsthereof are within normal range or at pre-administration baseline levelsat about or by about 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 1week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9weeks 10 weeks, 11 weeks, 12 weeks, 13 weeks, 14 weeks, 15 weeks, 16weeks, 4 months, 17 weeks, 18 weeks, 19 weeks, 20 weeks, 21 weeks, 22weeks, 23 weeks, 24 weeks, 25 weeks, 26 weeks, 27 weeks, 28 weeks, 29weeks, 30 weeks, 31 weeks, 32 weeks, 33 weeks, 34 weeks, 35 weeks, 36weeks, 37 weeks, 38 weeks, 39 weeks, 40 weeks, 41 weeks, 42 weeks, 43weeks, 44 weeks, 45 weeks, 46 weeks, 47 weeks, 48 weeks, 49 weeks, 50weeks, 51 weeks, 52 weeks, or 1 year. In various embodiments, theadministration of the ASBTI does not result in a statisticallysignificant change from baseline in serum bilirubin concentration, serumAST concentration, serum ALT concentration, serum alkaline phosphataseconcentration, or some combination thereof for a period of at leastabout or of about 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 1 week,2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks10 weeks, 11 weeks, 12 weeks, 13 weeks, 14 weeks, 15 weeks, 16 weeks, 4months, 17 weeks, 18 weeks, 19 weeks, 20 weeks, 21 weeks, 22 weeks, 23weeks, 24 weeks, 25 weeks, 26 weeks, 27 weeks, 28 weeks, 29 weeks, 30weeks, 31 weeks, 32 weeks, 33 weeks, 34 weeks, 35 weeks, 36 weeks, 37weeks, 38 weeks, 39 weeks, 40 weeks, 41 weeks, 42 weeks, 43 weeks, 44weeks, 45 weeks, 46 weeks, 47 weeks, 48 weeks, 49 weeks, 50 weeks, 51weeks, 52 weeks, or 1 year.

Pharmaceutical Compositions

In some embodiments, the ASBTI is administered as a pharmaceuticalcomposition comprising an ASBTI (the composition or the pharmaceuticalcomposition). Any composition described herein can be formulated forileal, rectal and/or colonic delivery. In more specific embodiments, thecomposition is formulated for non-systemic or local delivery to therectum and/or colon. It is to be understood that, as used herein,delivery to the colon includes delivery to sigmoid colon, transversecolon, and/or ascending colon. In still more specific embodiments, thecomposition is formulated for non-systemic or local delivery to therectum and/or colon is administered rectally. In other specificembodiments, the composition is formulated for non-systemic or localdelivery to the rectum and/or colon is administered orally.

Provided herein, in certain embodiments, is a pharmaceutical compositioncomprising a therapeutically effective amount of any compound describedherein. In certain instances, the pharmaceutical composition comprisesan ASBT inhibitor (e.g., any ASBTI described herein).

In certain embodiments, pharmaceutical compositions are formulated in aconventional manner using one or more physiologically acceptablecarriers including, e.g., excipients and auxiliaries which facilitateprocessing of the active compounds into preparations which are suitablefor pharmaceutical use. In certain embodiments, proper formulation isdependent upon the route of administration chosen. A summary ofpharmaceutical compositions described herein is found, for example, inRemington: The Science and Practice of Pharmacy, Nineteenth Ed (Easton,Pa.: Mack Publishing Company, 1995); Hoover, John E., Remington'sPharmaceutical Sciences, Mack Publishing Co., Easton, Pa. 1975;Liberman, H. A. and Lachman, L., Eds., Pharmaceutical Dosage Forms,Mareel Decker, New York, N.Y., 1980; and Pharmaceutical Dosage Forms andDrug Delivery Systems, Seventh Ed. (Lippincott Williams & Wilkins 1999),all of which references are incorporated herein in their entirety forall purposes.

A pharmaceutical composition, as used herein, refers to a mixture of acompound described herein, with other chemical components, such ascarriers, stabilizers, diluents, dispersing agents, suspending agents,thickening agents, and/or excipients. In certain instances, thepharmaceutical composition facilitates administration of the compound toan individual or cell. In certain embodiments of practicing the methodsof treatment or use provided herein, therapeutically effective amountsof compounds described herein are administered in a pharmaceuticalcomposition to an individual having a disease, disorder, or condition tobe treated. In specific embodiments, the individual is a human. Asdiscussed herein, the compounds described herein are either utilizedsingly or in combination with one or more additional therapeutic agents.

In certain embodiments, the pharmaceutical formulations described hereinare administered to an individual in any manner, including one or moreof multiple administration routes, such as, by way of non-limitingexample, oral, parenteral (e.g., intravenous, subcutaneous,intramuscular), intranasal, buccal, topical, rectal, or transdermaladministration routes.

In certain embodiments, a pharmaceutical compositions described hereinincludes one or more compound described herein as an active ingredientin free-acid or free-base form, or in a pharmaceutically acceptable saltform. In some embodiments, the compounds described herein are utilizedas an N-oxide or in a crystalline or amorphous form (i.e., a polymorph).In some situations, a compound described herein exists as tautomers. Alltautomers are included within the scope of the compounds presentedherein. In certain embodiments, a compound described herein exists in anunsolvated or solvated form, wherein solvated forms comprise anypharmaceutically acceptable solvent, e.g., water, ethanol, and the like.The solvated forms of the compounds presented herein are also consideredto be described herein.

A “carrier” includes, in some embodiments, a pharmaceutically acceptableexcipient and is selected on the basis of compatibility with compoundsdescribed herein, such as, compounds of any of Formula I-VI, and therelease profile properties of the desired dosage form. Exemplary carriermaterials include, e.g., binders, suspending agents, disintegrationagents, filling agents, surfactants, solubilizers, stabilizers,lubricants, wetting agents, diluents, and the like. See, e.g.,Remington: The Science and Practice of Pharmacy, Nineteenth Ed (Easton,Pa.: Mack Publishing Company, 1995); Hoover, John E., Remington'sPharmaceutical Sciences, Mack Publishing Co., Easton, Pa. 1975;Liberman, H. A. and Lachman, L., Eds., Pharmaceutical Dosage Forms,Mareel Decker, New York, N.Y., 1980; and Pharmaceutical Dosage Forms andDrug Delivery Systems, Seventh Ed. (Lippincott Williams & Wilkins 1999),all of which references are incorporated herein in their entirety forall purposes.

Moreover, in certain embodiments, the pharmaceutical compositionsdescribed herein are formulated as a dosage form. As such, in someembodiments, provided herein is a dosage form comprising a compounddescribed herein, suitable for administration to an individual. Incertain embodiments, suitable dosage forms include, by way ofnon-limiting example, aqueous oral dispersions, liquids, gels, syrups,elixirs, slurries, suspensions, solid oral dosage forms, aerosols,controlled release formulations, fast melt formulations, effervescentformulations, lyophilized formulations, tablets, powders, pills,dragees, capsules, delayed release formulations, extended releaseformulations, pulsatile release formulations, multiparticulateformulations, and mixed immediate release and controlled releaseformulations.

In some embodiments, provided herein is a composition comprising anenteroendocrine peptide secretion enhancing agent and, optionally, apharmaceutically acceptable carrier for alleviating symptoms ofcholestasis or a cholestatic liver disease in an individual.

In certain embodiments, the composition comprises an enteroendocrinepeptide secretion enhancing agent and an absorption inhibitor. Inspecific embodiments, the absorption inhibitor is an inhibitor thatinhibits the absorption of the (or at least one of the) specificenteroendocrine peptide secretion enhancing agent with which it iscombined. In some embodiments, the composition comprises anenteroendocrine peptide secretion enhancing agent, an absorptioninhibitor and a carrier (e.g., an orally suitable carrier or a rectallysuitable carrier, depending on the mode of intended administration). Incertain embodiments, the composition comprises an enteroendocrinepeptide secretion enhancing agent, an absorption inhibitor, a carrier,and one or more of a cholesterol absorption inhibitor, anenteroendocrine peptide, a peptidase inhibitor, a spreading agent, and awetting agent.

In other embodiments, the compositions described herein are administeredorally for non-systemic delivery of the ASBTI to the rectum and/orcolon, including the sigmoid colon, transverse colon, and/or ascendingcolon. In specific embodiments, compositions formulated for oraladministration are, by way of non-limiting example, enterically coatedor formulated oral dosage forms, such as, tablets and/or capsules.

Absorption Inhibitors

In certain embodiments, the composition described herein as beingformulated for the non-systemic delivery of ASBTI further includes anabsorption inhibitor. As used herein, an absorption inhibitor includesan agent or group of agents that inhibit absorption of a bile acid/salt.

Suitable bile acid absorption inhibitors (also described herein asabsorption inhibiting agents) may include, by way of non-limitingexample, anionic exchange matrices, polyamines, quaternary aminecontaining polymers, quaternary ammonium salts, polyallylamine polymersand copolymers, colesevelam, colesevelam hydrochloride, CholestaGel(N,N,N-trimethyl-6-(2-propenylamino)-1-hexanaminium chloride polymerwith (chloromethyl)oxirane, 2-propen-1-amine andN-2-propenyl-1-decanamine hydrochloride), cyclodextrins, chitosan,chitosan derivatives, carbohydrates which bind bile acids, lipids whichbind bile acids, proteins and proteinaceous materials which bind bileacids, and antibodies and albumins which bind bile acids. Suitablecyclodextrins include those that bind bile acids/salts such as, by wayof non-limiting example, β-cyclodextrin andhydroxypropyl-β-cyclodextrin. Suitable proteins, include those that bindbile acids/salts such as, by way of non-limiting example, bovine serumalbumin, egg albumin, casein, α-acid glycoprotein, gelatin, soyproteins, peanut proteins, almond proteins, and wheat vegetableproteins.

In certain embodiments the absorption inhibitor is cholestyramine. Inspecific embodiments, cholestyramine is combined with a bile acid.Cholestyramine, an ion exchange resin, is a styrene polymer containingquaternary ammonium groups crosslinked by divinylbenzene. In otherembodiments, the absorption inhibitor is colestipol. In specificembodiments, colestipol is combined with a bile acid. Colestipol, an ionexchange resin, is a copolymer of diethylenetriamine and1-chloro-2,3-epoxypropane.

In certain embodiments of the compositions and methods described hereinthe ASBTI is linked to an absorption inhibitor, while in otherembodiments the ASBTI and the absorption inhibitor are separatemolecular entities.

Cholesterol Absorption Inhibitors

In certain embodiments, a composition described herein optionallyincludes at least one cholesterol absorption inhibitor. Suitablecholesterol absorption inhibitors include, by way of non-limitingexample, ezetimibe (SCH 58235), ezetimibe analogs, ACT inhibitors,stigmastanyl phosphorylcholine, stigmastanyl phosphorylcholineanalogues, β-lactam cholesterol absorption inhibitors, sulfatepolysaccharides, neomycin, plant sponins, plant sterols, phytostanolpreparation FM-VP4, Sitostanol, β-sitosterol,acyl-CoA:cholesterol-O-acyltransferase (ACAT) inhibitors, Avasimibe,Implitapide, steroidal glycosides and the like. Suitable enzetimibeanalogs include, by way of non-limiting example, SCH 48461, SCH 58053and the like. Suitable ACT inhibitors include, by way of non-limitingexample, trimethoxy fatty acid anilides such as Cl-976,3-[decyldimethylsilyl]-N-[2-(4-methylphenyl)-1-phenylethyl]-propanamide,melinamide and the like. β-lactam cholesterol absorption inhibitorsinclude, by way of non-limiting example,βR-4S)-1,4-bis-(4-methoxyphenyl)-3-β-phenylpropyl)-2-azetidinone and thelike.

Peptidase Inhibitors

In some embodiments, the compositions described herein optionallyinclude at least one peptidase inhibitor. Such peptidase inhibitorsinclude, but are not limited to, dipeptidyl peptidase-4 inhibitors(DPP-4), neutral endopeptidase inhibitors, and converting enzymeinhibitors. Suitable dipeptidyl peptidase-4 inhibitors (DPP-4) include,by way of non-limiting example, Vildaglipti,2.S)-1-{2-[β-hydroxy-1-adamantyl)amino]acetyl}pyrrolidine-2-carbonitrile,Sitagliptin,βR)-3-amino-1-[9-(trifluoromethyl)-1,4,7,8-tetrazabicyclo[4.3.0]nona-6,8-dien-4-yl]-4-(2,4,5-trifluorophenyl)butan-1-one,Saxagliptin, and(1S,3S,5S)-2-[(2S)-2-amino-2-β-hydroxy-1-adamantyl)acetyl]-2-azabicyclo[3.1.0]hexane-3-carbonitrile.Such neutral endopeptidase inhibitors include, but are not limited to,Candoxatrilat and Ecadotril.

Spreading Agents Wetting Agents

In certain embodiments, the composition described herein optionallycomprises a spreading agent. In some embodiments, a spreading agent isutilized to improve spreading of the composition in the colon and/orrectum. Suitable spreading agents include, by way of non-limitingexample, hydroxyethylcellulose, hydroxypropymethyl cellulose,polyethylene glycol, colloidal silicon dioxide, propylene glycol,cyclodextrins, microcrystalline cellulose, polyvinylpyrrolidone,polyoxyethylated glycerides, polycarbophil, di-n-octyl ethers,Cetiol™OE, fatty alcohol polyalkylene glycol ethers, Aethoxal™B),2-ethylhexyl palmitate, Cegesoft™C 24), and isopropyl fatty acid esters.

In some embodiments, the compositions described herein optionallycomprise a wetting agent. In some embodiments, a wetting agent isutilized to improve wettability of the composition in the colon andrectum. Suitable wetting agents include, by way of non-limiting example,surfactants. In some embodiments, surfactants are selected from, by wayof non-limiting example, polysorbate (e.g., 20 or 80), stearylhetanoate, caprylic/capric fatty acid esters of saturated fatty alcoholsof chain length C₁₂-C₁₈, isostearyl diglycerol isostearic acid, sodiumdodecyl sulphate, isopropyl myristate, isopropyl palmitate, andisopropyl myristate/isopropyl stearate/isopropyl palmitate mixture.

Vitamins

In some embodiments, the methods provided herein further compriseadministering one or more vitamins.

In some embodiments, the vitamin is vitamin A, B1, B2, B3, B5, B6, B7,B9, B12, C, D, E, K, folic acid, pantothenic acid, niacin, riboflavin,thiamine, retinol, beta carotene, pyridoxine, ascorbic acid,cholecalciferol, cyanocobalamin, tocopherols, phylloquinone,menaquinone.

In some embodiments, the vitamin is a fat-soluble vitamin such asvitamin A, D, E, K, retinol, beta carotene, cholecalciferol,tocopherols, phylloquinone. In a preferred embodiment, the fat-solublevitamin is tocopherol polyethylene glycol succinate (TPGS).

Bile Acid Sequestrants Binders

In some embodiments, a labile bile acid sequestrant is an enzymedependent bile acid sequestrant. In certain embodiments, the enzyme is abacterial enzyme. In some embodiments, the enzyme is a bacterial enzymefound in high concentration in human colon or rectum relative to theconcentration found in the small intestine. Examples of micro-floraactivated systems include dosage forms comprising pectin, galactomannan,and/or Azo hydrogels and/or glycoside conjugates (e.g., conjugates ofD-galactoside, 3-D-xylopyranoside or the like) of the active agent.Examples of gastrointestinal micro-flora enzymes include bacterialglycosidases such as, for example, D-galactosidase, 3-D-glucosidase,α-L-arabinofuranosidase, β-D-xylopyranosidase or the like.

In certain embodiments, a labile bile acid sequestrant is atime-dependent bile acid sequestrant. In some embodiments, a labile bileacid sequestrant releases a bile acid or is degraded after 1, 2, 3, 4,5, 6, 7, 8, 9, or 10 seconds of sequestration. In some embodiments, alabile bile acid sequestrant releases a bile acid or is degraded after15, 20, 25, 30, 35, 40, 45, 50, or 55 seconds of sequestration. In someembodiments, a labile bile acid sequestrant releases a bile acid or isdegraded after 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 minutes ofsequestration. In some embodiments, a labile bile acid sequestrantreleases a bile acid or is degraded after about 15, 20, 25, 30, 35, 45,50, or 55 minutes of sequestration. In some embodiments, a labile bileacid sequestrant releases a bile acid or is degraded after about 1, 2,3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22,23, or 24 hours of sequestration. In some embodiments, a labile bileacid sequestrant releases a bile acid or is degraded after 1, 2, or 3days of sequestration.

In some embodiments, the labile bile acid sequestrant has a low affinityfor bile acid. In certain embodiments, the labile bile acid sequestranthas a high affinity for a primary bile acid and a low affinity for asecondary bile acid.

In some embodiments, the labile bile acid sequestrant is a pH dependentbile acid sequestrant. In certain embodiments, the pH dependent bileacid sequestrant has a high affinity for bile acid at a pH of 6 or belowand a low affinity for bile acid at a pH above 6. In certainembodiments, the pH dependent bile acid sequestrant has a high affinityfor bile acid at a pH of 6.5 or below and a low affinity for bile acidat a pH above 6.5. In certain embodiments, the pH dependent bile acidsequestrant has a high affinity for bile acid at a pH of 7 or below anda low affinity for bile acid at a pH above 7. In certain embodiments,the pH dependent bile acid sequestrant has a high affinity for bile acidat a pH of 7.1 or below and a low affinity for bile acid at a pH above7.1. In certain embodiments, the pH dependent bile acid sequestrant hasa high affinity for bile acid at a pH of 7.2 or below and a low affinityfor bile acid at a pH above 7.2. In certain embodiments, the pHdependent bile acid sequestrant has a high affinity for bile acid at apH of 7.3 or below and a low affinity for bile acid at a pH above 7.3.In certain embodiments, the pH dependent bile acid sequestrant has ahigh affinity for bile acid at a pH of 7.4 or below and a low affinityfor bile acid at a pH above 7.4. In certain embodiments, the pHdependent bile acid sequestrant has a high affinity for bile acid at apH of 7.5 or below and a low affinity for bile acid at a pH above 7.5.In certain embodiments, the pH dependent bile acid sequestrant has ahigh affinity for bile acid at a pH of 7.6 or below and a low affinityfor bile acid at a pH above 7.6. In certain embodiments, the pHdependent bile acid sequestrant has a high affinity for bile acid at apH of 7.7 or below and a low affinity for bile acid at a pH above 7.7.In certain embodiments, the pH dependent bile acid sequestrant has ahigh affinity for bile acid at a pH of 7.8 or below and a low affinityfor bile acid at a pH above 7.8. In some embodiments, the pH dependentbile acid sequestrant degrades at a pH above 6. In some embodiments, thepH dependent bile acid sequestrant degrades at a pH above 6.5. In someembodiments, the pH dependent bile acid sequestrant degrades at a pHabove 7. In some embodiments, the pH dependent bile acid sequestrantdegrades at a pH above 7.1. In some embodiments, the pH dependent bileacid sequestrant degrades at a pH above 7.2. In some embodiments, the pHdependent bile acid sequestrant degrades at a pH above 7.3. In someembodiments, the pH dependent bile acid sequestrant degrades at a pHabove 7.4. In some embodiments, the pH dependent bile acid sequestrantdegrades at a pH above 7.5. In some embodiments, the pH dependent bileacid sequestrant degrades at a pH above 7.6. In some embodiments, the pHdependent bile acid sequestrant degrades at a pH above 7.7. In someembodiments, the pH dependent bile acid sequestrant degrades at a pHabove 7.8. In some embodiments, the pH dependent bile acid sequestrantdegrades at a pH above 7.9.

In certain embodiments, the labile bile acid sequestrant is lignin or amodified lignin. In some embodiments, the labile bile acid sequestrantis a polycationic polymer or copolymer. In certain embodiments, thelabile bile acid sequestrant is a polymer or copolymer comprising one ormore N-alkenyl-N-alkylamine residues; one or moreN,N,N-trialkyl-N—(N′-alkenylamino)alkyl-azanium residues; one or moreN,N,N-trialkyl-N-alkenyl-azanium residues; one or more alkenyl-amineresidues; or a combination thereof. In some embodiments, the bile acidbinder is cholestyramine, and various compositions includingcholestyramine, which are described, for example, in U.S. Pat. Nos.3,383,281; 3,308,020; 3,769,399; 3,846,541; 3,974,272; 4,172,120;4,252,790; 4,340,585; 4,814,354; 4,874,744; 4,895,723; 5,695,749; and6,066,336, all of which are incorporated herein by reference in theirentirety for all purposes. In some embodiments, the bile acid binder ischolestipol or cholesevelam.

Routes of Administration, Dosage Forms, and Dosing Regimens

In some embodiments, the compositions described herein, and thecompositions administered in the methods described herein are formulatedto inhibit bile acid reuptake or reduce serum or hepatic bile acidlevels. In certain embodiments, the compositions described herein areformulated for rectal or oral administration. In some embodiments, suchformulations are administered rectally or orally, respectively. In someembodiments, the compositions described herein are combined with adevice for local delivery of the compositions to the rectum and/or colon(sigmoid colon, transverse colon, or ascending colon). In certainembodiments, for rectal administration the composition described hereinare formulated as enemas, rectal gels, rectal foams, rectal aerosols,suppositories, jelly suppositories, or retention enemas. In someembodiments, for oral administration the compositions described hereinare formulated for oral administration and enteric delivery to thecolon.

In certain embodiments, the compositions or methods described herein arenon-systemic. In some embodiments, compositions described herein deliverthe ASBTI to the distal ileum, colon, and/or rectum and not systemically(e.g., a substantial portion of the enteroendocrine peptide secretionenhancing agent is not systemically absorbed). In some embodiments, oralcompositions described herein deliver the ASBTI to the distal ileum,colon, and/or rectum and not systemically (e.g., a substantial portionof the enteroendocrine peptide secretion enhancing agent is notsystemically absorbed). In some embodiments, rectal compositionsdescribed herein deliver the ASBTI to the distal ileum, colon, and/orrectum and not systemically (e.g., a substantial portion of theenteroendocrine peptide secretion enhancing agent is not systemicallyabsorbed). In certain embodiments, non-systemic compositions describedherein deliver less than 90% w/w of the ASBTI systemically. In certainembodiments, non-systemic compositions described herein deliver lessthan 80% w/w of the ASBTI systemically. In certain embodiments,non-systemic compositions described herein deliver less than 70% w/w ofthe ASBTI systemically. In certain embodiments, non-systemiccompositions described herein deliver less than 60% w/w of the ASBTIsystemically. In certain embodiments, non-systemic compositionsdescribed herein deliver less than 50% w/w of the ASBTI systemically. Incertain embodiments, non-systemic compositions described herein deliverless than 40% w/w of the ASBTI systemically. In certain embodiments,non-systemic compositions described herein deliver less than 30% w/w ofthe ASBTI systemically. In certain embodiments, non-systemiccompositions described herein deliver less than 25% w/w of the ASBTIsystemically. In certain embodiments, non-systemic compositionsdescribed herein deliver less than 20% w/w of the ASBTI systemically. Incertain embodiments, non-systemic compositions described herein deliverless than 15% w/w of the ASBTI systemically. In certain embodiments,non-systemic compositions described herein deliver less than 10% w/w ofthe ASBTI systemically. In certain embodiments, non-systemiccompositions described herein deliver less than 5% w/w of the ASBTIsystemically. In some embodiments, systemic absorption is determined inany suitable manner, including the total circulating amount, the amountcleared after administration, or the like.

In certain embodiments, the compositions and/or formulations describedherein are administered at least once a day. In certain embodiments, theformulations containing the ASBTI are administered at least twice a day,while in other embodiments the formulations containing the ASBTI areadministered at least three times a day. In certain embodiments, theformulations containing the ASBTI are administered up to five times aday. It is to be understood that in certain embodiments, the dosageregimen of composition containing the ASBTI described herein to isdetermined by considering various factors such as the patient's age,sex, and diet.

The concentration of the ASBTI administered in the formulationsdescribed herein ranges from about 1 mM to about 1 M. In certainembodiments the concentration of the ASBTI administered in theformulations described herein ranges from about 1 mM to about 750 mM. Incertain embodiments the concentration of the ASBTI administered in theformulations described herein ranges from about 1 mM to about 500 mM. Incertain embodiments the concentration of the ASBTI administered in theformulations described herein ranges from about 5 mM to about 500 mM. Incertain embodiments the concentration of the ASBTI administered in theformulations described herein ranges from about 10 mM to about 500 mM.In certain embodiments the concentration of the administered in theformulations described herein ranges from about 25 mM to about 500 mM.In certain embodiments the concentration of the ASBTI administered inthe formulations described herein ranges from about 50 mM to about 500mM. In certain embodiments the concentration of the ASBTI administeredin the formulations described herein ranges from about 100 mM to about500 mM. In certain embodiments the concentration of the ASBTIadministered in the formulations described herein ranges from about 200mM to about 500 mM.

In certain embodiments, by targeting the distal gastrointestinal tract(e.g., distal ileum, colon, and/or rectum), compositions and methodsdescribed herein provide efficacy (e.g., in reducing microbial growthand/or alleviating symptoms of cholestasis or a cholestatic liverdisease) with a reduced dose of enteroendocrine peptide secretionenhancing agent (e.g., as compared to an oral dose that does not targetthe distal gastrointestinal tract).

Rectal Administration Formulations

The pharmaceutical compositions described herein for the non-systemicdelivery of a compound described herein to the rectum and/or colon areformulated for rectal administration as rectal enemas, rectal foams,rectal gels, and rectal suppositories. The components of suchformulations are described herein. It is to be understood that as usedherein, pharmaceutical compositions and compositions are or comprise theformulations as described herein. In some embodiments, rectalformulations comprise rectal enemas, foams, gels, or suppositories.

In certain embodiments, liquid carrier vehicles or co-solvents in thecompositions and/or formulations described herein include, by way ofnon-limiting example, purified water, propylene glycol, PEG200, PEG300,PEG400, PEG600, polyethyleneglycol, ethanol, 1-propanol, 2-propanol,1-propen-3-ol (allyl alcohol), propylene glycol, glycerol,2-methyl-2-propanol, formamide, methyl formamide, dimethyl formamide,ethyl formamide, diethyl formamide, acetamide, methyl acetamide,dimethyl acetamide, ethyl acetamide, diethyl acetamide, 2-pyrrolidone,N-methyl-2-pyrrolidone, N-ethyl-2-pyrrolidone, tetramethyl urea,1,3-dimethyl-2-imidazolidinone, propylene carbonate, 1,2-butylenecarbonate, 2,3-butylene carbonate, dimethyl sulfoxide, diethylsulfoxide, hexamethyl phosphoramide, pyruvic aldehyde dimethylacetal,dimethylisosorbide and combinations thereof.

In some embodiments, stabilizers used in compositions and/orformulations described herein include, but are not limited to, partialglycerides of polyoxyethylenic saturated fatty acids.

In certain embodiments, surfactants/emulsifiers used in the compositionsand/or formulations described herein include, by way of non-limitingexample, mixtures of cetostearylic alcohol with sorbitan esterified withpolyoxyethylenic fatty acids, polyoxyethylene fatty ethers,polyoxyethylene fatty esters, fatty acids, sulfated fatty acids,phosphated fatty acids, sulfosuccinates, amphoteric surfactants,non-ionic poloxamers, non-ionic meroxapols, petroleum derivatives,aliphatic amines, polysiloxane derivatives, sorbitan fatty acid esters,laureth-4, PEG-2 dilaurate, stearic acid, sodium lauryl sulfate, dioctylsodium sulfosuccinate, cocoamphopropionate, poloxamer 188, meroxapol258, triethanolamine, dimethicone, polysorbate 60, sorbitanmonostearate, pharmaceutically acceptable salts thereof, andcombinations thereof.

In some embodiments, non-ionic surfactants used in compositions and/orformulations described herein include, by way of non-limiting example,phospholipids, alkyl poly(ethylene oxide), poloxamers (e.g., poloxamer188), polysorbates, sodium dioctyl sulfosuccinate, Brij™-30 (Laureth-4),Brij™-58 (Ceteth-20) and Brij™-78 (Steareth-20), Brij™-721(Steareth-21), Crillet-1 (Polysorbate 20), Crillet-2 (Polysorbate 40),Crillet-3 (Polysorbate 60), Crillet 45 (Polysorbate 80), Myrj-52 (PEG-40Stearate), Myrj-53 (PEG-50 Stearate), Pluronic™ F77 (Poloxamer 217),Pluronic™ F87 (Poloxamer 237), Pluronic™ F98 (Poloxamer 288), Pluronic™L62 (Poloxamer 182), Pluronic™ L64 (Poloxamer 184), Pluronic™ F68(Poloxamer 188), Pluronic™ L81 (Poloxamer 231), Pluronic™ L92 (Poloxamer282), Pluronic™ L101 (Poloxamer 331), Pluronic™ P103 (Poloxamer 333),Pluracare™ F 108 NF (Poloxamer 338), and Pluracare™ F 127 NF (Poloxamer407) and combinations thereof. Pluronic™ polymers are commerciallypurchasable from BASF, USA and Germany.

In certain embodiments, anionic surfactants used in compositions and/orformulations described herein include, by way of non-limiting example,sodium laurylsulphate, sodium dodecyl sulfate (SDS), ammonium laurylsulfate, alkyl sulfate salts, alkyl benzene sulfonate, and combinationsthereof.

In some embodiments, the cationic surfactants used in compositionsand/or formulations described herein include, by way of non-limitingexample, benzalkonium chloride, benzethonium chloride, cetyltrimethylammonium bromide, hexadecyl trimethyl ammonium bromide, otheralkyltrimethylammonium salts, cetylpyridinium chloride, polyethoxylatedtallow and combinations thereof.

In certain embodiments, the thickeners used in compositions and/orformulations described herein include, by way of non-limiting example,natural polysaccharides, semi-synthetic polymers, synthetic polymers,and combinations thereof. Natural polysaccharides include, by way ofnon-limiting example, acacia, agar, alginates, carrageenan, guar,arabic, tragacanth gum, pectins, dextran, gellan and xanthan gums.Semi-synthetic polymers include, by way of non-limiting example,cellulose esters, modified starehes, modified celluloses,carboxymethylcellulose, methyl cellulose, ethyl cellulose, hydroxyethylcellulose, hydroxypropyl cellulose and hydroxypropyl methylcellulose.Synthetic polymers include, by way of non-limiting example,polyoxyalkylenes, polyvinyl alcohol, polyacrylamide, polyacrylates,carboxypolymethylene (carbomer), polyvinylpyrrolidone (povidones),polyvinylacetate, polyethylene glycols and poloxamer. Other thickenersinclude, by way of nonlimiting example, polyoxyethyleneglycolisostearate, cetyl alcohol, Polyglycol 300 isostearate, propyleneglycol,collagen, gelatin, and fatty acids (e.g., lauric acid, myristic acid,palmitic acid, stearic acid, palmitoleic acid, linoleic acid, linolenicacid, oleic acid and the like).

In some embodiments, chelating agents used in the compositions and/orformulations described herein include, by way of non-limiting example,ethylenediaminetetraacetic acid (EDTA) or salts thereof, phosphates andcombinations thereof.

In some embodiments, the concentration of the chelating agent or agentsused in the rectal formulations described herein is a suitableconcentration, e.g., about 0.1%, 0.15%, 0.2%, 0.25%, 0.3%, 0.4%, or 0.5%(w/v).

In some embodiments, preservatives used in compositions and/orformulations described herein include, by way of non-limiting example,parabens, ascorbyl palmitate, benzoic acid, butylated hydroxyanisole,butylated hydroxytoluene, chlorobutanol, ethylenediamine, ethylparaben,methylparaben, butyl paraben, propylparaben, monothioglycerol, phenol,phenylethyl alcohol, propylparaben, sodium benzoate, sodium propionate,sodium formaldehyde sulfoxylate, sodium metabisulfite, sorbic acid,sulfur dioxide, maleic acid, propyl gallate, benzalkonium chloride,benzethonium chloride, benzyl alcohol, chlorhexidine acetate,chlorhexidine gluconate, sorbic acid, potassium sorbitol, chlorbutanol,phenoxyethanol, cetylpyridinium chloride, phenylmercuric nitrate,thimerosol, and combinations thereof.

In certain embodiments, antioxidants used in compositions and/orformulations described herein include, by way of non-limiting example,ascorbic acid, ascorbyl palmitate, butylated hydroxyanisole, butylatedhydroxytoluene, hypophosphorous acid, monothioglycerol, propyl gallate,sodium ascorbate, sodium sulfite, sodium bisulfite, sodium formaldehydesulfoxylate, potassium metabisulphite, sodium metabisulfite, oxygen,quinones, t-butyl hydroquinone, erythorbic acid, olive (olea eurpaea)oil, pentasodium penetetate, pentetic acid, tocopheryl, tocopherylacetate and combinations thereof.

In some embodiments, concentration of the antioxidant or antioxidantsused in the rectal formulations described herein is sufficient toachieve a desired result, e.g., about 0.1%, 0.15%, 0.2%, 0.25%, 0.3%,0.4%, or 0.5% (w/v).

The lubricating agents used in compositions and/or formulationsdescribed herein include, by way of non-limiting example, natural orsynthetic fat or oil (e.g., a tris-fatty acid glycerate and the like).In some embodiments, lubricating agents include, by way of non-limitingexample, glycerin (also called glycerine, glycerol, 1,2,3-propanetriol,and trihydroxypropane), polyethylene glycols (PEGs), polypropyleneglycol, polyisobutene, polyethylene oxide, behenic acid, behenylalcohol, sorbitol, mannitol, lactose, polydimethylsiloxane andcombinations thereof.

In certain embodiments, mucoadhesive and/or bioadhesive polymers areused in the compositions and/or formulations described herein as agentsfor inhibiting absorption of the enteroendocrine peptide secretionenhancing agent across the rectal or colonic mucosa. Bioadhesive ormucoadhesive polymers include, by way of non-limiting example,hydroxypropyl cellulose, polyethylene oxide homopolymers, polyvinylether-maleic acid copolymers, methyl cellulose, ethyl cellulose, propylcellulose, hydroxyethyl cellulose, hydroxypropyl cellulose,hydroxypropylmcthyl cellulose, carboxymethylcellulose, polycarbophil,polyvinylpyrrolidone, carbopol, polyurethanes, polyethyleneoxide-polypropyline oxide copolymers, sodium carboxymethyl cellulose,polyethylene, polypropylene, lectins, xanthan gum, alginates, sodiumalginate, polyacrylic acid, chitosan, hyaluronic acid and esterderivatives thereof, vinyl acetate homopolymer, calcium polycarbophil,gelatin, natural gums, karaya, tragacanth, algin, chitosan, starehes,pectins, and combinations thereof.

In some embodiments, buffers/pH adjusting agents used in compositionsand/or formulations described herein include, by way of non-limitingexample, phosphoric acid, monobasic sodium or potassium phosphate,triethanolamine (TRIS), BICINE, HEPES, Trizma, glycine, histidine,arginine, lysine, asparagine, aspartic acid, glutamine, glutamic acid,carbonate, bicarbonate, potassium metaphosphate, potassium phosphate,monobasic sodium acetate, acetic acid, acetate, citric acid, sodiumcitrate anhydrous, sodium citrate dihydrate and combinations thereof. Incertain embodiments, an acid or a base is added to adjust the pH.Suitable acids or bases include, by way of non-limiting example, HCL,NaOH and KOH.

In certain embodiments, concentration of the buffering agent or agentsused in the rectal formulations described herein is sufficient toachieve or maintain a physiologically desirable pH, e.g., about 0.1%,0.2%, 0.3%, 0.4%, 0.5%, 0.6%, 0.8%, 0.9%, or 1.0% (w/w).

The tonicity modifiers used in compositions and/or formulationsdescribed herein include, by way of non-limiting example, sodiumchloride, potassium chloride, sodium phosphate, mannitol, sorbitol orglucose.

Oral Administration for Colonic Delivery

In certain aspects, the composition or formulation containing one ormore compounds described herein is orally administered for localdelivery of an ASBTI, or a compound described herein to the colon and/orrectum. Unit dosage forms of such compositions include a pill, tablet orcapsules formulated for enteric delivery to colon. In certainembodiments, such pills, tablets or capsule contain the compositionsdescribed herein entrapped or embedded in microspheres. In someembodiments, microspheres include, by way of non-limiting example,chitosan microcores HPMC capsules and cellulose acetate butyrate (CAB)microspheres. In certain embodiments, oral dosage forms are preparedusing conventional methods known to those in the field of pharmaceuticalformulation. For example, in certain embodiments, tablets aremanufactured using standard tablet processing procedures and equipment.An exemplary method for forming tablets is by direct compression of apowdered, crystalline or granular composition containing the activeagent(s), alone or in combination with one or more carriers, additives,or the like. In alternative embodiments, tablets are prepared usingwet-granulation or dry-granulation processes. In some embodiments,tablets are molded rather than compressed, starting with a moist orotherwise tractable material.

In certain embodiments, tablets prepared for oral administration containvarious excipients, including, by way of non-limiting example, binders,diluents, lubricants, disintegrants, fillers, stabilizers, surfactants,preservatives, coloring agents, flavoring agents and the like. In someembodiments, binders are used to impart cohesive qualities to a tablet,ensuring that the tablet remains intact after compression. Suitablebinder materials include, by way of non-limiting example, stareh(including corn stareh and pregelatinized stareh), gelatin, sugars(including sucrose, glucose, dextrose and lactose), polyethylene glycol,propylene glycol, waxes, and natural and synthetic gums, e.g., acaciasodium alginate, polyvinylpyrrolidone, cellulosic polymers (includinghydroxypropyl cellulose, hydroxypropyl methylcellulose, methylcellulose, ethyl cellulose, hydroxyethyl cellulose, and the like),Veegum, and combinations thereof. In certain embodiments, diluents areutilized to increase the bulk of the tablet so that a practical sizetablet is provided. Suitable diluents include, by way of non-limitingexample, dicalcium phosphate, calcium sulfate, lactose, cellulose,kaolin, mannitol, sodium chloride, dry stareh, powdered sugar andcombinations thereof. In certain embodiments, lubricants are used tofacilitate tablet manufacture; examples of suitable lubricants include,by way of non-limiting example, vegetable oils such as peanut oil,cottonseed oil, sesame oil, olive oil, corn oil, and oil of theobroma,glycerin, magnesium stearate, calcium stearate, stearic acid andcombinations thereof. In some embodiments, disintegrants are used tofacilitate disintegration of the tablet, and include, by way ofnon-limiting example, starehes, clays, celluloses, algins, gums,crosslinked polymers and combinations thereof. Fillers include, by wayof non-limiting example, materials such as silicon dioxide, titaniumdioxide, alumina, talc, kaolin, powdered cellulose and microcrystallinecellulose, as well as soluble materials such as mannitol, urea, sucrose,lactose, dextrose, sodium chloride and sorbitol. In certain embodiments,stabilizers are used to inhibit or retard drug decomposition reactionsthat include, by way of example, oxidative reactions. In certainembodiments, surfactants are anionic, cationic, amphoteric or nonionicsurface active agents.

In some embodiments, ASBTIs, or other compounds described herein areorally administered in association with a carrier suitable for deliveryto the distal gastrointestinal tract (e.g., distal ileum, colon, and/orrectum).

In certain embodiments, a composition described herein comprises anASBTI, or other compounds described herein in association with a matrix(e.g., a matrix comprising hypermellose) that allows for controlledrelease of an active agent in the distal part of the ileum and/or thecolon. In some embodiments, a composition comprises a polymer that is pHsensitive (e.g., a MMX™ matrix from Cosmo Pharmaceuticals) and allowsfor controlled release of an active agent in the distal part of theileum. Examples of such pH sensitive polymers suitable for controlledrelease include and are not limited to polyacrylic polymers (e.g.,anionic polymers of methacrylic acid and/or methacrylic acid esters,e.g., Carbopol® polymers) that comprise acidic groups (e.g., —COOH,—SO₃H) and swell in basic pH of the intestine (e.g., pH of about 7 toabout 8). In some embodiments, a composition suitable for controlledrelease in the distal ileum comprises microparticulate active agent(e.g., micronized active agent). In some embodiments, anon-enzymatically degrading poly(dl-lactide-co-glycolide) (PLGA) core issuitable for delivery of an enteroendocrine peptide secretion enhancingagent to the distal ileum. In some embodiments, a dosage form comprisingan enteroendocrine peptide secretion enhancing agent is coated with anenteric polymer (e.g., Eudragit® S-100, cellulose acetate phthalate,polyvinylacetate phthalate, hydroxypropylmethylcellulose phthalate,anionic polymers of methacrylic acid, methacrylic acid esters or thelike) for site specific delivery to the distal ileum and/or the colon.In some embodiments, bacterially activated systems are suitable fortargeted delivery to the distal part of the ileum. Examples ofmicro-flora activated systems include dosage forms comprising pectin,galactomannan, and/or Azo hydrogels and/or glycoside conjugates (e.g.,conjugates of D-galactoside, β-D-xylopyranoside or the like) of theactive agent. Examples of gastrointestinal micro-flora enzymes includebacterial glycosidases such as, for example, D-galactosidase,β-D-glucosidase, α-L-arabinofuranosidase, β-D-xylopyranosidase or thelike.

The pharmaceutical composition described herein optionally include anadditional therapeutic compound described herein and one or morepharmaceutically acceptable additives such as a compatible carrier,binder, filling agent, suspending agent, flavoring agent, sweeteningagent, disintegrating agent, dispersing agent, surfactant, lubricant,colorant, diluent, solubilizer, moistening agent, plasticizer,stabilizer, penetration enhancer, wetting agent, anti-foaming agent,antioxidant, preservative, or one or more combination thereof. In someaspects, using standard coating procedures, such as those described inRemington's Pharmaceutical Sciences, 20th Edition (2000), a film coatingis provided around the formulation of the compound of Formula I. In oneembodiment, a compound described herein is in the form of a particle andsome or all of the particles of the compound are coated. In certainembodiments, some or all of the particles of a compound described hereinare microencapsulated. In some embodiments, the particles of thecompound described herein are not microencapsulated and are uncoated.

In further embodiments, a tablet or capsule comprising an ASBTI or othercompounds described herein is film-coated for delivery to targeted siteswithin the gastrointestinal tract. Examples of enteric film coatsinclude and are not limited to hydroxypropylmethylcellulose, polyvinylpyrrolidone, hydroxypropyl cellulose, polyethylene glycol 3350, 4500,8000, methyl cellulose, pseudoethylcellulose, amylopectin and the like.

Pediatric Dosage Formulations and Compositions

Provided herein, in certain embodiments, is a pediatric dosageformulation or composition comprising a therapeutically effective amountof any compound described herein. In certain instances, thepharmaceutical composition comprises an ASBT inhibitor (e.g., any ASBTIdescribed herein).

In certain embodiments, suitable dosage forms for the pediatric dosageformulation or composition include, by way of non-limiting example,aqueous or non-aqueous oral dispersions, liquids, gels, syrups, elixirs,slurries, suspensions, solutions, controlled release formulations, fastmelt formulations, effervescent formulations, lyophilized formulations,chewable tablets, gummy candy, orally disintegrating tablets, powdersfor reconstitution as suspension or solution, sprinkle oral powder orgranules, dragees, delayed release formulations, extended releaseformulations, pulsatile release formulations, multiparticulateformulations, and mixed immediate release and controlled releaseformulations. In some embodiments, provided herein is a pharmaceuticalcomposition wherein the pediatric dosage form is selected from asolution, syrup, suspension, elixir, powder for reconstitution assuspension or solution, dispersible/effervescent tablet, chewabletablet, gummy candy, lollipop, freezer pops, troches, oral thin strips,orally disintegrating tablet, orally disintegrating strip, sachet, andsprinkle oral powder or granules.

In another aspect, provide herein is a pharmaceutical compositionwherein at least one excipient is a flavoring agent or a sweetener. Insome embodiments, provided herein is a coating. In some embodiments,provided herein is a taste-masking technology selected from coating ofdrug particles with a taste-neutral polymer by spray-drying, wetgranulation, fluidized bed, and microencapsulation; coating with moltenwaxes of a mixture of molten waxes and other pharmaceutical adjuvants;entrapment of drug particles by complexation, flocculation orcoagulation of an aqueous polymeric dispersion; adsorption of drugparticles on resin and inorganic supports; and solid dispersion whereina drug and one or more taste neutral compounds are melted and cooled, orco-precipitated by a solvent evaporation. In some embodiments, providedherein is a delayed or sustained release formulation comprising drugparticles or granules in a rate controlling polymer or matrix.

Suitable sweeteners include sucrose, glucose, fructose or intensesweeteners, i.e. agents with a high sweetening power when compared tosucrose (e.g. at least 10 times sweeter than sucrose). Suitable intensesweeteners comprise aspartame, saccharin, sodium or potassium or calciumsaccharin, acesulfame potassium, sucralose, alitame, xylitol, cyclamate,neomate, neohesperidine dihydrochalcone or mixtures thereof, thaumatin,palatinit, stevioside, rebaudioside, Magnasweet®. The totalconcentration of the sweeteners may range from effectively zero to about300 mg/ml based on the liquid composition upon reconstitution.

In order to increase the palatability of the liquid composition uponreconstitution with an aqueous medium, one or more taste-making agentsmay be added to the composition in order to mask the taste of the ASBTinhibitor. A taste-masking agent can be a sweetener, a flavoring agentor a combination thereof. The taste-masking agents typically provide upto about 0.10% or 5% by weight of the total pharmaceutical composition.In a preferred embodiment of the present invention, the compositioncontains both sweetener(s) and flavor(s).

A flavoring agent herein is a substance capable of enhancing taste oraroma of a composition. Suitable natural or synthetic flavoring agentscan be selected from standard reference books, for example Fenaroli'sHandbook of Flavor Ingredients, 3rd edition (1995). Non-limitingexamples of flavoring agents and/or sweeteners useful in theformulations described herein, include, e.g., acacia syrup, acesulfameK, alitame, anise, apple, aspartame, banana, Bavarian cream, berry,black currant, butterscotch, calcium citrate, camphor, caramel, cherry,cherry cream, chocolate, cinnamon, bubble gum, citrus, citrus punch,citrus cream, cotton candy, cocoa, cola, cool cherry, cool citrus,cyclamate, cylamate, dextrose, eucalyptus, eugenol, fructose, fruitpunch, ginger, glycyrrhetinate, glycyrrhiza (licorice) syrup, grape,grapefruit, honey, isomalt, lemon, lime, lemon cream, monoammoniumglyrrhizinate (MagnaSweet®), maltol, mannitol, maple, marshmallow,menthol, mint cream, mixed berry, neohesperidine DC, neotame, orange,pear, peach, peppermint, peppermint cream, Prosweet® Powder, raspberry,root beer, rum, saccharin, safrole, sorbitol, spearmint, spearmintcream, strawberry, strawberry cream, stevia, sucralose, sucrose, sodiumsaccharin, saccharin, aspartame, acesulfame potassium, mannitol, talin,sylitol, sucralose, sorbitol, Swiss cream, tagatose, tangerine,thaumatin, tutti fruitti, vanilla, walnut, watermelon, wild cherry,wintergreen, xylitol, or any combination of these flavoring ingredients,e.g., anise-menthol, cherry-anise, cinnamon-orange, cherry-cinnamon,chocolate-mint, honey-lemon, lemon-lime, lemon-mint, menthol-eucalyptus,orange-cream, vanilla-mint, and mixtures thereof. Flavoring agents canbe used singly or in combinations of two or more. In some embodiments,the aqueous liquid dispersion comprises a sweetening agent or flavoringagent in a concentration ranging from about 0.001% to about 5.0% thevolume of the aqueous dispersion. In one embodiment, the aqueous liquiddispersion comprises a sweetening agent or flavoring agent in aconcentration ranging from about 0.001% to about 1.0% the volume of theaqueous dispersion. In another embodiment, the aqueous liquid dispersioncomprises a sweetening agent or flavoring agent in a concentrationranging from about 0.005% to about 0.5% the volume of the aqueousdispersion. In yet another embodiment, the aqueous liquid dispersioncomprises a sweetening agent or flavoring agent in a concentrationranging from about 0.010% to about 1.0% the volume of the aqueousdispersion. In yet another embodiment, the aqueous liquid dispersioncomprises a sweetening agent or flavoring agent in a concentrationranging from about 0.01% to about 0.5% the volume of the aqueousdispersion.

In certain embodiments, a pediatric pharmaceutical composition describedherein includes one or more compound described herein as an activeingredient in free-acid or free-base form, or in a pharmaceuticallyacceptable salt form. In some embodiments, the compounds describedherein are utilized as an N-oxide or in a crystalline or amorphous form(i.e., a polymorph). In some situations, a compound described hereinexists as tautomers. All tautomers are included within the scope of thecompounds presented herein. In certain embodiments, a compound describedherein exists in an unsolvated or solvated form, wherein solvated formscomprise any pharmaceutically acceptable solvent, e.g., water, ethanol,and the like. The solvated forms of the compounds presented herein arealso considered to be described herein.

A “carrier” for pediatric pharmaceutical compositions includes, in someembodiments, a pharmaceutically acceptable excipient and is selected onthe basis of compatibility with compounds described herein, such as,compounds of any of Formula I-VI, and the release profile properties ofthe desired dosage form. Exemplary carrier materials include, e.g.,binders, suspending agents, disintegration agents, filling agents,surfactants, solubilizers, stabilizers, lubricants, wetting agents,diluents, and the like. See, e.g., Remington: The Science and Practiceof Pharmacy, Nineteenth Ed (Easton, Pa.: Mack Publishing Company, 1995);Hoover, John E., Remington's Pharmaceutical Sciences, Mack PublishingCo., Easton, Pa. 1975; Liberman, H. A. and Lachman, L., Eds.,Pharmaceutical Dosage Forms, Marcel Decker, New York, N.Y., 1980; andPharmaceutical Dosage Forms and Drug Delivery Systems, Seventh Ed.(Lippincott Williams & Wilkins 1999), all of which references areincorporated herein by reference in their entirety for all purposes.

Moreover, in certain embodiments, the pediatric pharmaceuticalcompositions described herein are formulated as a dosage form. As such,in some embodiments, provided herein is a dosage form comprising acompound described herein, suitable for administration to an individual.In certain embodiments, suitable dosage forms include, by way ofnon-limiting example, aqueous oral dispersions, liquids, gels, syrups,elixirs, slurries, suspensions, solid oral dosage forms, aerosols,controlled release formulations, fast melt formulations, effervescentformulations, lyophilized formulations, tablets, powders, pills,dragees, capsules, delayed release formulations, extended releaseformulations, pulsatile release formulations, multiparticulateformulations, and mixed immediate release and controlled releaseformulations.

In certain aspects, the pediatric composition or formulation containingone or more compounds described herein is orally administered for localdelivery of an ASBTI, or a compound described herein to the colon and/orrectum. Unit dosage forms of such compositions include a pill, tablet orcapsules formulated for enteric delivery to colon. In certainembodiments, such pills, tablets or capsule contain the compositionsdescribed herein entrapped or embedded in microspheres. In someembodiments, microspheres include, by way of non-limiting example,chitosan microcores HPMC capsules and cellulose acetate butyrate (CAB)microspheres. In certain embodiments, oral dosage forms are preparedusing conventional methods known to those in the field of pharmaceuticalformulation. For example, in certain embodiments, tablets aremanufactured using standard tablet processing procedures and equipment.An exemplary method for forming tablets is by direct compression of apowdered, crystalline or granular composition containing the activeagent(s), alone or in combination with one or more carriers, additives,or the like. In alternative embodiments, tablets are prepared usingwet-granulation or dry-granulation processes. In some embodiments,tablets are molded rather than compressed, starting with a moist orotherwise tractable material.

In certain embodiments, tablets prepared for oral administration containvarious excipients, including, by way of non-limiting example, binders,diluents, lubricants, disintegrants, fillers, stabilizers, surfactants,preservatives, coloring agents, flavoring agents and the like. In someembodiments, binders are used to impart cohesive qualities to a tablet,ensuring that the tablet remains intact after compression. Suitablebinder materials include, by way of non-limiting example, starch(including corn starch and pregelatinized starch), gelatin, sugars(including sucrose, glucose, dextrose and lactose), polyethylene glycol,propylene glycol, waxes, and natural and synthetic gums, e.g., acaciasodium alginate, polyvinylpyrrolidone, cellulosic polymers (includinghydroxypropyl cellulose, hydroxypropyl methylcellulose, methylcellulose, ethyl cellulose, hydroxyethyl cellulose, and the like),Veegum, and combinations thereof. In certain embodiments, diluents areutilized to increase the bulk of the tablet so that a practical sizetablet is provided. Suitable diluents include, by way of non-limitingexample, dicalcium phosphate, calcium sulfate, lactose, cellulose,kaolin, mannitol, sodium chloride, dry starch, powdered sugar andcombinations thereof. In certain embodiments, lubricants are used tofacilitate tablet manufacture; examples of suitable lubricants include,by way of non-limiting example, vegetable oils such as peanut oil,cottonseed oil, sesame oil, olive oil, corn oil, and oil of theobroma,glycerin, magnesium stearate, calcium stearate, stearic acid andcombinations thereof. In some embodiments, disintegrants are used tofacilitate disintegration of the tablet, and include, by way ofnon-limiting example, starches, clays, celluloses, algins, gums,crosslinked polymers and combinations thereof. Fillers include, by wayof non-limiting example, materials such as silicon dioxide, titaniumdioxide, alumina, talc, kaolin, powdered cellulose and microcrystallinecellulose, as well as soluble materials such as mannitol, urea, sucrose,lactose, dextrose, sodium chloride and sorbitol. In certain embodiments,stabilizers are used to inhibit or retard drug decomposition reactionsthat include, by way of example, oxidative reactions. In certainembodiments, surfactants are anionic, cationic, amphoteric or nonionicsurface active agents.

In some embodiments, ASBTIs, or other compounds described herein areorally administered in association with a carrier suitable for deliveryto the distal gastrointestinal tract (e.g., distal ileum, colon, and/orrectum).

In certain embodiments, a pediatric composition described hereincomprises an ASBTI, or other compounds described herein in associationwith a matrix (e.g., a matrix comprising hypermellose) that allows forcontrolled release of an active agent in the distal part of the ileumand/or the colon. In some embodiments, a composition comprises a polymerthat is pH sensitive (e.g., a MMX™ matrix from Cosmo Pharmaceuticals)and allows for controlled release of an active agent in the distal partof the ileum. Examples of such pH sensitive polymers suitable forcontrolled release include and are not limited to polyacrylic polymers(e.g., anionic polymers of methacrylic acid and/or methacrylic acidesters, e.g., Carbopol® polymers) that comprise acidic groups (e.g.,—COOH, —SO₃H) and swell in basic pH of the intestine (e.g., pH of about7 to about 8). In some embodiments, a composition suitable forcontrolled release in the distal ileum comprises microparticulate activeagent (e.g., micronized active agent). In some embodiments, anon-enzymatically degrading poly(dl-lactide-co-glycolide) (PLGA) core issuitable for delivery of an enteroendocrine peptide secretion enhancingagent to the distal ileum. In some embodiments, a dosage form comprisingan enteroendocrine peptide secretion enhancing agent is coated with anenteric polymer (e.g., Eudragit® S-100, cellulose acetate phthalate,polyvinylacetate phthalate, hydroxypropylmethylcellulose phthalate,anionic polymers of methacrylic acid, methacrylic acid esters or thelike) for site specific delivery to the distal ileum and/or the colon.In some embodiments, bacterially activated systems are suitable fortargeted delivery to the distal part of the ileum. Examples ofmicro-flora activated systems include dosage forms comprising pectin,galactomannan, and/or Azo hydrogels and/or glycoside conjugates (e.g.,conjugates of D-galactoside, β-D-xylopyranoside or the like) of theactive agent. Examples of gastrointestinal micro-flora enzymes includebacterial glycosidases such as, for example, D-galactosidase,β-D-glucosidase, α-L-arabinofuranosidase, β-D-xylopyranosidase or thelike.

The pediatric pharmaceutical composition described herein optionallyinclude an additional therapeutic compound described herein and one ormore pharmaceutically acceptable additives such as a compatible carrier,binder, filling agent, suspending agent, flavoring agent, sweeteningagent, disintegrating agent, dispersing agent, surfactant, lubricant,colorant, diluent, solubilizer, moistening agent, plasticizer,stabilizer, penetration enhancer, wetting agent, anti-foaming agent,antioxidant, preservative, or one or more combination thereof. In someaspects, using standard coating procedures, such as those described inRemington's Pharmaceutical Sciences, 20th Edition (2000), a film coatingis provided around the formulation of the compound of Formula I. In oneembodiment, a compound described herein is in the form of a particle andsome or all of the particles of the compound are coated. In certainembodiments, some or all of the particles of a compound described hereinare microencapsulated. In some embodiments, the particles of thecompound described herein are not microencapsulated and are uncoated.

In further embodiments, a tablet or capsule comprising an ASBTI or othercompounds described herein is film-coated for delivery to targeted siteswithin the gastrointestinal tract. Examples of enteric film coatsinclude and are not limited to hydroxypropylmethylcellulose, polyvinylpyrrolidone, hydroxypropyl cellulose, polyethylene glycol 3350, 4500,8000, methyl cellulose, pseudo ethylcellulose, amylopectin and the like.

Solid Dosage Forms for Pediatric Administration

Solid dosage forms for pediatric administration of the present inventioncan be manufactured by standard manufacturing techniques. Non-limitingexamples of oral solid dosage forms for pediatric administration aredescribed below.

Effervescent Compositions

The effervescent compositions of the invention may be prepared accordingto techniques well-known in the art of pharmacy.

Effervescent formulations contain and effervescent couple of a basecomponent and an acid component, which components reach in the presenceof water to generate a gas. In some embodiments, the base component maycomprise, for example, an alkali metal or alkaline earth metalcarbonate, or bicarbonate. The acid component may comprise, for example,an aliphatic carboxylic acid or a salt thereof, such as citric acid. Thebase and acid components may each independently constitute, for example,25% to 55% (w/w) of the effervescent composition. The ratio of acidcomponent to base component may be within the range of 1:2 to 2:1.

The effervescent compositions of the invention may be formulated usingadditional pharmaceutically acceptable carriers or excipients asappropriate. For example, one or more taste masking agents may be used.Dyes may also be used, as pediatric patients often prefer colorfulpharmaceutical combinations. The compositions may take the form of, forexample, tablets, granules or powders, granules or powders presented ina sachet.

Chewable Tablets

The chewable tablets of the invention may be prepared according totechniques well-known in the art of pharmacy.

Chewable tablets are tablets that are intended to disintegrate in themouth under the action of chewing or sucking and where, in consequence,the active ingredient has greater opportunity to come into contact withthe bitter-taste receptors on the tongue.

One method of overcoming this issue is to absorb the active ingredientonto a suitable substrate. This approach is known in the art anddescribed for example in U.S. Pat. No. 4,647,459, which is incorporatedherein by reference in its entirety for all purposes.

Another approach involves forming the active ingredient into anaggregate along with a pre-swelled substantially anhydrous hydrocolloid.The hydrocolloid absorbs saliva and acquires a slippery texture whichenables it to lubricate the particles of aggregate and mask the taste ofthe active ingredient. This approach is known in the art and describedfor example in European patent application 0190826, which isincorporated herein by reference in its entirety for all purposes.

Another approach involves employing a water-insoluble hygroscopicexcipient such as microcrystalline cellulose. This approach is known inthe art and described for example in U.S. Pat. No. 5,275,823, which isincorporated herein by reference in its entirety for all purposes.

In addition to the above approaches, the chewable tablets of the presentinvention can also contain other standard tableting excipients such as adisintegrant and a taste-masking agent.

Orodispersible Tablets

The orodispersible tablets of the invention may be prepared according totechniques well-known in the art of pharmacy.

In orodispersible tablets of the invention, the excipient mixtures aresuch as to provide it with a disintegration rate so that itsdisintegration in the buccal cavity occurs in an extremely short timeand especially shorter than sixty seconds. In some embodiments, theexcipient mixture is characterized by the fact that the active substanceis in the form of coated or non-coated microcrystals of microgranules.In some embodiments, the orodispersible tablet comprises one or severaldisintegrating agents of the carboxymethylcellulose type or insolublereticulated PVP type, one or several swelling agents which may comprisea carboxymethylcellulose, a starch, a modified starch, or amicrocrystalline cellulose or optionally a direct compression sugar.

Powders for Reconstitution

The powder for reconstitution pharmaceutical compositions of theinvention may be prepared according to techniques well-known in the artof pharmacy.

In some embodiments, the powder for reconstitution compositions of theinvention comprise an effective amount of at least one internaldehydrating agent. The internal dehydrating agent can enhance thestability of the powder. In some embodiments, the internal dehydratingagent is magnesium citrate or disodium carbonate. In some embodiments,the powder composition comprises a pharmaceutically acceptable diluents,such as sucrose, dextrose, mannitol, xylitol, or lactose.

Powder compositions of the inventions may be placed in sachets orbottles for contemporaneous dissolution or for short term storage inliquid form (e.g. 7 days).

Gummy Candies

The gummy candies of the invention may be prepared according totechniques well-known in the art of pharmacy.

Traditional gummy candy is made from a gelatin base. Gelatin gives thecandy its elasticity, the desired chewy consistency, and a longer shelflife. In some embodiments, the gummy candy pharmaceutical composition ofthe invention includes a binding agent, a sweetener, and an activeingredient.

In some embodiments, the binding agent is a pectin gel, gelatin, foodstarch, or any combination thereof.

In some embodiments, the gummy candy comprises sweeteners, a bindingagent, natural and/or artificial flavors and colors and preservatives.In some embodiments, the gummy candy comprises glucose syrup, naturalcane juice, gelatin, citric acid, lactic acid, natural colors, naturalflavors, fractionated coconut oil, and carnauba wax.

Liquid Dosage Forms

The pharmaceutical liquid dosage forms of the invention may be preparedaccording to techniques well-known in the art of pharmacy.

A solution refers to a liquid pharmaceutical formulation wherein theactive ingredient is dissolved in the liquid. Pharmaceutical solutionsof the invention include syrups and elixirs. A suspension refers to aliquid pharmaceutical formulation wherein the active ingredient is in aprecipitate in the liquid.

In a liquid dosage form, it is desirable to have a particular pH and/orto be maintained within a specific pH range. In order to control the pH,a suitable buffer system can be used. In addition, the buffer systemshould have sufficient capacity to maintain the desired pH range.Examples of the buffer system useful in the present invention includebut are not limited to, citrate buffers, phosphate buffers, or any othersuitable buffer known in the art. Preferably the buffer system includesodium citrate, potassium citrate, sodium bicarbonate, potassiumbicarbonate, sodium dihydrogen phosphate and potassium dihydrogenphosphate, etc. The concentration of the buffer system in the finalsuspension varies according to factors such as the strength of thebuffer system and the pH/pH ranges required for the liquid dosage form.In one embodiment, the concentration is within the range of 0.005 to 0.5w/v % in the final liquid dosage form.

The pharmaceutical composition comprising the liquid dosage form of thepresent invention can also include a suspending/stabilizing agent toprevent settling of the active material. Over time the settling couldlead to caking of the active to the inside walls of the product pack,leading to difficulties with redispersion and accurate dispensing.Suitable stabilizing agents include but are not limited to, thepolysaccharide stabilizers such as xanthan, guar and tragacanth gums aswell as the cellulose derivatives HPMC (hydroxypropyl methylcellulose),methyl cellulose and Avicel RC-591 (microcrystalline cellulose/sodiumcarboxymethyl cellulose). In another embodiment, polyvinylpyrrolidone(PVP) can also be used as a stabilizing agent.

In addition to the aforementioned components, the ASBTI oral suspensionform can also optionally contain other excipients commonly found inpharmaceutical compositions such as alternative solvents, taste-maskingagents, antioxidants, fillers, acidifiers, enzyme inhibitors and othercomponents as described in Handbook of Pharmaceutical Excipients, Roweet al., Eds., 4^(th) Edition, Pharmaceutical Press (2003), which ishereby incorporated by reference in its entirety for all purposes.

Addition of an alternative solvent may help increase solubility of anactive ingredient in the liquid dosage form, and consequently theabsorption and bioavailability inside the body of a subject. Preferablythe alternative solvents include methanol, ethanol or propylene glycoland the like.

In another aspect, the present invention provides a process forpreparing the liquid dosage form. The process comprises steps ofbringing ASBTI or its pharmaceutically acceptable salts thereof intomixture with the components including glycerol or syrup or the mixturethereof, a preservative, a buffer system and a suspending/stabilizingagent, etc., in a liquid medium. In general, the liquid dosage form isprepared by uniformly and intimately mixing these various components inthe liquid medium. For example, the components such as glycerol or syrupor the mixture thereof, a preservative, a buffer system and asuspending/stabilizing agent, etc., can be dissolved in water to formthe aqueous solution, then the active ingredient can be then dispersedin the aqueous solution to form a suspension.

In some embodiments, the liquid dosage form provided herein can be in avolume of between about 5 ml to about 50 ml. In some embodiments, theliquid dosage form provided herein can be in a volume of between about 5ml to about 40 ml. In some embodiments, the liquid dosage form providedherein can be in a volume of between about 5 ml to about 30 ml. In someembodiments, the liquid dosage form provided herein can be in a volumeof between about 5 ml to about 20 ml. In some embodiments, the liquiddosage form provided herein can be in a volume of between about 10 ml toabout 30 ml. In some embodiments, the liquid dosage form provided hereincan be in a volume of about 20 ml. In some embodiments, the ASBTI can bein an amount ranging from about 0.001% to about 90% of the total volume.In some embodiments, the ASBTI can be in an amount ranging from about0.01% to about 80% of the total volume. In some embodiments, the ASBTIcan be in an amount ranging from about 0.10% to about 70% of the totalvolume. In some embodiments, the ASBTI can be in an amount ranging fromabout 1% to about 60% of the total volume. In some embodiments, theASBTI can be in an amount ranging from about 1% to about 50% of thetotal volume. In some embodiments, the ASBTI can be in an amount rangingfrom about 1% to about 40% of the total volume. In some embodiments, theASBTI can be in an amount ranging from about 1% to about 30% of thetotal volume. In some embodiments, the ASBTI can be in an amount rangingfrom about 1% to about 20% of the total volume. In some embodiments, theASBTI can be in an amount ranging from about 1% to about 10% of thetotal volume. In some embodiments, the ASBTI can be in an amount rangingfrom about 5% to about 70% of the total volume. In some embodiments, theASBTI can be in an amount ranging from about 5% to about 60% of thetotal volume. In some embodiments, the ASBTI can be in an amount rangingfrom about 5% to about 50% of the total volume. In some embodiments, theASBTI can be in an amount ranging from about 5% to about 40% of thetotal volume. In some embodiments, the ASBTI can be in an amount rangingfrom about 5% to about 30% of the total volume. In some embodiments, theASBTI can be in an amount ranging from about 5% to about 20% of thetotal volume. In some embodiments, the ASBTI can be in an amount rangingfrom about 5% to about 10% of the total volume. In some embodiments, theASBTI can be in an amount ranging from about 10% to about 50% of thetotal volume. In some embodiments, the ASBTI can be in an amount rangingfrom about 10% to about 40% of the total volume. In some embodiments,the ASBTI can be in an amount ranging from about 10% to about 30% of thetotal volume. In some embodiments, the ASBTI can be in an amount rangingfrom about 10% to about 20% of the total volume. In one embodiment, theresulted liquid dosage form can be in a liquid volume of 10 ml to 30 ml,preferably 20 ml, and the active ingredient can be in an amount rangingfrom about 0.001 mg/ml to about 16 mg/ml, or from about 0.025 mg/ml toabout 8 mg/ml, or from about 0.1 mg/ml to about 4 mg/ml, or about 0.25mg/ml, or about 0.5 mg/ml, or about 1 mg/ml, or about 2 mg/ml, or about4 mg/ml, or about 5 mg/ml, or about 8 mg/ml, or about 10 mg/ml, or about12 mg/ml, or about 14 mg/ml or about 16 mg/ml.

Bile Acid Sequestrant

In certain embodiments, an oral formulation for use in any methoddescribed herein is, e.g., an ASBTI in association with a labile bileacid sequestrant. A labile bile acid sequestrant is a bile acidsequestrant with a labile affinity for bile acids. In certainembodiments, a bile acid sequestrant described herein is an agent thatsequesters (e.g., absorbs or is charged with) bile acid, and/or thesalts thereof.

In specific embodiments, the labile bile acid sequestrant is an agentthat sequesters (e.g., absorbs or is charged with) bile acid, and/or thesalts thereof, and releases at least a portion of the absorbed orcharged bile acid, and/or salts thereof in the distal gastrointestinaltract (e.g., the colon, ascending colon, sigmoid colon, distal colon,rectum, or any combination thereof). In certain embodiments, the labilebile acid sequestrant is an enzyme dependent bile acid sequestrant. Inspecific embodiments, the enzyme is a bacterial enzyme. In someembodiments, the enzyme is a bacterial enzyme found in highconcentration in human colon or rectum relative to the concentrationfound in the small intestine. Examples of micro-flora activated systemsinclude dosage forms comprising pectin, galactomannan, and/or Azohydrogels and/or glycoside conjugates (e.g., conjugates ofD-galactoside, R-D-xylopyranoside or the like) of the active agent.Examples of gastrointestinal micro-flora enzymes include bacterialglycosidases such as, for example, D-galactosidase, β-D-glucosidase,α-L-arabinofuranosidase, β-D-xylopyranosidase or the like. In someembodiments, the labile bile acid sequestrant is a time dependent bileacid sequestrant (i.e., the bile acid sequesters the bile acid and/orsalts thereof and after a time releases at least a portion of the bileacid and/or salts thereof). In some embodiments, a time dependent bileacid sequestrant is an agent that degrades in an aqueous environmentover time. In certain embodiments, a labile bile acid sequestrantdescribed herein is a bile acid sequestrant that has a low affinity forbile acid and/or salts thereof, thereby allowing the bile acidsequestrant to continue to sequester bile acid and/or salts thereof inan environ where the bile acids/salts and/or salts thereof are presentin high concentration and release them in an environ wherein bileacids/salts and/or salts thereof are present in a lower relativeconcentration. In some embodiments, the labile bile acid sequestrant hasa high affinity for a primary bile acid and a low affinity for asecondary bile acid, allowing the bile acid sequestrant to sequester aprimary bile acid or salt thereof and subsequently release a secondarybile acid or salt thereof as the primary bile acid or salt thereof isconverted (e.g., metabolized) to the secondary bile acid or saltthereof. In some embodiments, the labile bile acid sequestrant is a pHdependent bile acid sequestrant. In some embodiments, the pH dependentbile acid sequestrant has a high affinity for bile acid at a pH of 6 orbelow and a low affinity for bile acid at a pH above 6. In certainembodiments, the pH dependent bile acid sequestrant degrades at a pHabove 6.

In some embodiments, labile bile acid sequestrants described hereininclude any compound, e.g., a macro-structured compound, that cansequester bile acids/salts and/or salts thereof through any suitablemechanism. For example, in certain embodiments, bile acid sequestrantssequester bile acids/salts and/or salts thereof through ionicinteractions, polar interactions, static interactions, hydrophobicinteractions, lipophilic interactions, hydrophilic interactions, stericinteractions, or the like. In certain embodiments, macrostructuredcompounds sequester bile acids/salts and/or sequestrants by trapping thebile acids/salts and/or salts thereof in pockets of the macrostructuredcompounds and, optionally, other interactions, such as those describedabove. In some embodiments, bile acid sequestrants (e.g., labile bileacid sequestrants) include, by way of non-limiting example, lignin,modified lignin, polymers, polycationic polymers and copolymers,polymers and/or copolymers comprising anyone one or more ofN-alkenyl-N-alkylaminc residues; one or moreN,N,N-trialkyl-N—(N′-alkenylamino)alkyl-azanium residues; one or moreN,N,N-trialkyl-N-alkenyl-azanium residues; one or more alkenyl-amineresidues; or a combination thereof, or any combination thereof.

Covalent Linkage of the Drug with a Carrier

In some embodiments, strategies used for colon targeted deliveryinclude, by way of non-limiting example, covalent linkage of the ASBTIor other compounds described herein to a carrier, coating the dosageform with a pH-sensitive polymer for delivery upon reaching the pHenvironment of the colon, using redox sensitive polymers, using a timereleased formulation, utilizing coatings that are specifically degradedby colonic bacteria, using bioadhesive system and using osmoticallycontrolled drug delivery systems.

In certain embodiments of such oral administration of a compositioncontaining an ASBTI or other compounds described herein involvescovalent linking to a carrier wherein upon oral administration thelinked moiety remains intact in the stomach and small intestine. Uponentering the colon, the covalent linkage is broken by the change in pH,enzymes, and/or degradation by intestinal microflora. In certainembodiments, the covalent linkage between the ASBTI and the carrierincludes, by way of non-limiting example, azo linkage, glycosideconjugates, glucuronide conjugates, cyclodextrin conjugates, dextranconjugates, and amino-acid conjugates (high hydrophilicity and longchain length of the carrier amino acid).

Coating with Polymers: pH-Sensitive Polymers

In some embodiments, the oral dosage forms described herein are coatedwith an enteric coating to facilitate the delivery of an ASBTI or othercompounds described herein to the colon and/or rectum. In certainembodiments, an enteric coating is one that remains intact in the low pHenvironment of the stomach, but readily dissolved when the optimumdissolution pH of the particular coating is reached which depends uponthe chemical composition of the enteric coating. The thickness of thecoating will depend upon the solubility characteristics of the coatingmaterial. In certain embodiments, the coating thicknesses used in suchformulations described herein range from about 25 μm to about 200 μm.

In certain embodiments, the compositions or formulations describedherein are coated such that an ASBTI or other compounds described hereinof the composition or formulation is delivered to the colon and/orrectum without absorbing at the upper part of the intestine. In aspecific embodiment, specific delivery to the colon and/or rectum isachieved by coating of the dosage form with polymers that degrade onlyin the pH environment of the colon. In alternative embodiments, thecomposition is coated with an enteric coat that dissolves in the pH ofthe intestines and an outer layer matrix that slowly erodes in theintestine. In some of such embodiments, the matrix slowly erodes untilonly a core composition comprising an enteroendocrine peptide secretionenhancing agent (and, in some embodiments, an absorption inhibitor ofthe agent) is left and the core is delivered to the colon and/or rectum.

In certain embodiments, pH-dependent systems exploit the progressivelyincreasing pH along the human gastrointestinal tract (GIT) from thestomach (pH 1-2 which increases to 4 during digestion), small intestine(pH 6-7) at the site of digestion and it to 7-8 in the distal ileum. Incertain embodiments, dosage forms for oral administration of thecompositions described herein are coated with pH-sensitive polymer(s) toprovide delayed release and protect the enteroendocrine peptidesecretion enhancing agents from gastric fluid. In certain embodiments,such polymers are be able to withstand the lower pH values of thestomach and of the proximal part of the small intestine but disintegrateat the neutral or slightly alkaline pH of the terminal ileum and/orileocecal junction. Thus, in certain embodiments, provided herein is anoral dosage form comprising a coating, the coating comprising apH-sensitive polymer. In some embodiments, the polymers used for colonand/or rectum targeting include, by way of non-limiting example,methacrylic acid copolymers, methacrylic acid and methyl methacrylatecopolymers, Eudragit L100, Eudragit S100, Eudragit L-30D, EudragitFS-30D, Eudragit L100-55, polyvinylacetate phthalate, hyrdoxypropylethyl cellulose phthalate, hyrdoxypropyl methyl cellulose phthalate 50,hyrdoxypropyl methyl cellulose phthalate 55, cellulose acetatetrimelliate, cellulose acetate phthalate and combinations thereof.

In certain embodiments, oral dosage forms suitable for delivery to thecolon and/or rectum comprise a coating that has a biodegradable and/orbacteria degradable polymer or polymers that are degraded by themicroflora (bacteria) in the colon. In such biodegradable systemssuitable polymers include, by way of non-limiting example, azo polymers,linear-type-segmented polyurethanes containing azo groups,polygalactomannans, pectin, glutaraldehyde crosslinked dextran,polysaccharides, amylose, guar gum, pectin, chitosan, inulin,cyclodextrins, chondroitin sulphate, dextrans, locust bean gum,chondroitin sulphate, chitosan, poly (-caprolactone), polylactic acidand poly(lactic-co-glycolic acid).

In certain embodiments of such oral administration of compositionscontaining one or more ASBTIs or other compounds described herein, thecompositions are delivered to the colon without absorbing at the upperpart of the intestine by coating of the dosage forms with redoxsensitive polymers that are degraded by the microflora (bacteria) in thecolon. In such biodegradable systems such polymers include, by way ofnon-limiting example, redox-sensitive polymers containing an azo and/ora disulfide linkage in the backbone.

In some embodiments, compositions formulated for delivery to the colonand/or rectum are formulated for time-release. In some embodiments, timerelease formulations resist the acidic environment of the stomach,thereby delaying the release of the enteroendocrine peptide secretionenhancing agents until the dosage form enters the colon and/or rectum.

In certain embodiments the time released formulations described hereincomprise a capsule (comprising an enteroendocrine peptide secretionenhancing agent and an optional absorption inhibitor) with hydrogelplug. In certain embodiments, the capsule and hydrogel plug are coveredby a water-soluble cap and the whole unit is coated with an entericpolymer. When the capsule enters the small intestine the enteric coatingdissolves and the hydrogels plug swells and dislodges from the capsuleafter a period of time and the composition is released from the capsule.The amount of hydrogel is used to adjust the period of time to therelease the contents.

In some embodiments, provided herein is an oral dosage form comprising amulti-layered coat, wherein the coat comprises different layers ofpolymers having different pH-sensitivities. As the coated dosage formmoves along GIT the different layers dissolve depending on the pHencountered. Polymers used in such formulations include, by way ofnon-limiting example, polymethacrylates with appropriate pH dissolutioncharacteristics, Eudragit® RL and Eudragit®RS (inner layer), andEudragit® FS (outer layer). In other embodiments the dosage form is anenteric coated tablets having an outer shell of hydroxypropylcelluloseor hydroxypropylmethylcellulose acetate succinate (HPMCAS).

In some embodiments, provided herein is an oral dosage form thatcomprises coat with cellulose butyrate phthalate, cellulose hydrogenphthalate, cellulose proprionate phthalate, polyvinyl acetate phthalate,cellulose acetate phthalate, cellulose acetate trimellitate,hydroxypropyl methylcellulose phthalate, hydroxypropyl methylcelluloseacetate, dioxypropyl methylcellulose succinate, carboxymethylethylcellulose, hydroxypropyl methylcellulose acetate succinate,polymers and copolymers formed from acrylic acid, methacrylic acid, andcombinations thereof.

Combination Therapy

In some embodiments, the methods provided herein comprise administeringa compound (e.g., an ASBTI) or composition described herein incombination with one or more additional agents. In some embodiments, thepresent invention also provides a composition comprising a compound(e.g., an ASBTI) with one or more additional agents.

Fat Soluble Vitamins

In some embodiments, the methods provided herein further compriseadministering one or more vitamins. In some embodiments, the vitamin isvitamin A, B1, B2, B3, B5, B6, B7, B9, B12, C, D, E, K, folic acid,pantothenic acid, niacin, riboflavin, thiamine, retinol, beta carotene,pyridoxine, ascorbic acid, cholecalciferol, cyanocobalamin, tocopherols,phylloquinone, menaquinone.

In some embodiments, the vitamin is a fat soluble vitamin such asvitamin A, D, E, K, retinol, beta carotene, cholecalciferol,tocopherols, phylloquinone. In a preferred embodiment, the fat solublevitamin is tocopherol polyethylene glycol succinate (TPGS).

Partial External Biliary Diversion (PEBD)

In some embodiments, the methods provided herein further comprise usingpartial external biliary diversion as a treatment for patients who havenot yet developed cirrhosis. This treatment helps reduce the circulationof bile acids/salts in the liver in order to reduce complications andprevent the need for early transplantation in many patients.

This surgical technique involves isolating a segment of intestine 10 cmlong for use as a biliary conduit (a channel for the passage of bile)from the rest of the intestine. One end of the conduit is attached tothe gallbladder and the other end is brought out to the skin to form astoma (a surgically constructed opening to permit the passage of waste).Partial external biliary diversion may be used for patients who areunresponsive to all medical therapy, especially older, larger patients.This procedure may not be of help to young patients such as infants.Partial external biliary diversion may decrease the intensity of theitching and abnormally low levels of cholesterol in the blood.

ASBTIs and PPAR Agonists

In various embodiments, the present invention provides methods of use ofcombinations of ASBTIs with PPAR (peroxisome proliferator-activatedreceptor) agonists. In various embodiments, the PPAR agonist is afibrate drug. In some embodiments, the fibrate drug is clofibrate,gemfibrozil, ciprofibrate, benzafibrate, fenofibrate, or variouscombinations thereof. In various embodiments, the PPAR agonist isaleglitazar, muraglitazar, tesaglitazar, saroglitazar, GW501516,GW-9662, a thiazolidinedione (TZD), a NSAID (e.g., IBUPROFEN), anindole, or various combinations thereof.

ASBTIs and FXR Drugs

In various embodiments, the present invention provides methods of use ofcombinations of ASBTIs with famesoid X receptor (FXR) targeting drugs.In various embodiments, the FXR targeting drug is avermectin B1a,bepridil, fluticasone propionate, GW4064, gliquidone, nicardipine,triclosan, CDCA, ivermectin, chlorotrianisene, tribenoside, mometasonefuroate, miconazole, amiodarone, butoconazolee, bromocryptine mesylate,pizotifen malate, or various combinations thereof.

ASBTI and Ursodiol

In some embodiments, an ASBTI is administered in combination withursodiol or ursodeoxycholic acid, chenodeoxycholic acid, cholic acid,taurocholic acid, ursocholic acid, glycocholic acid, glycodeoxycholicacid, taurodeoxycholic acid, taurocholate, glycochenodeoxycholic acid,tauroursodeoxycholic acid. In some embodiments, an increase in theconcentration of bile acids/salts in the distal intestine inducesintestinal regeneration, attenuating intestinal injury, reducingbacterial translocation, inhibiting the release of free radical oxygen,inhibiting production of proinflammatory cytokines, or any combinationthereof or any combination thereof.

In certain embodiments, the patient is administered ursodiol at a dailydose of about or of at least about 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30mg, 35 mg, 36 mg, 40 mg, 45 mg, 50 mg, 55 mg, 60 mg, 65 mg, 70 mg, 75mg, 80 mg, 85 mg, 90 mg, 95 mg, 100 mg, 150 mg, 200 mg, 250 mg, 300 mg,350 mg, 400 mg, 450 mg, 500 mg, 550 mg, 600 mg, 650 mg, 700 mg, 750 mg,800 mg, 850 mg, 900 mg, 950 mg, 1,000 mg, 1,250 mg, 1,500 mg, 1,750 mg,2,000 mg, 2,250 mg, 2,500 mg, 2,750 mg, or 3,000 mg. In certainembodiments, the patient is administered ursodiol at a daily dose ofabout or of no more than about 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg,36 mg, 40 mg, 45 mg, 50 mg, 55 mg, 60 mg, 65 mg, 70 mg, 75 mg, 80 mg, 85mg, 90 mg, 95 mg, 100 mg, 150 mg, 200 mg, 250 mg, 300 mg, 350 mg, 400mg, 450 mg, 500 mg, 550 mg, 600 mg, 650 mg, 700 mg, 750 mg, 800 mg, 850mg, 900 mg, 950 mg, 1,000 mg, 1,250 mg, 1,500 mg, 1,750 mg, 2,000 mg,2,250 mg, 2,500 mg, 2,750 mg, 3,000 mg, or 3,500 mg. In variousembodiments, the patient is administered ursodiol at a daily dose ofabout or of at least about 3 mg to about 300 mg, about 30 mg to about250 mg, from about 36 mg to about 200 mg, from about 10 mg to about 3000mg, from about 1000 mg to about 2000 mg, or from about 1500 to about1900 mg.

In various embodiments the ursodiol is administered as a tablet. Invarious embodiments, the ursodiol is administered as a suspension. Invarious embodiments, the concentration of ursodiol in the suspension isfrom about 10 mg/mL to about 200 mg/mL, from about 50 mg/mL to about 150mg/mL, from about 10 mg/mL to about 500 mg/mL, or from about 40 mg/mL toabout 60 mg/mL. In various embodiments, the concentration of ursodiol insuspension is about or is at least about 20 mg/mL, 25 mg/mL, 30 mg/mL,35 mg/mL, 40 mg/mL, 45 mg/mL, 50 mg/mL, 55 mg/mL, 60 mg/mL, 65 mg/mL, 70mg/mL, 75 mg/mL, or 80 mg/mL. In various embodiments, the concentrationof ursodiol in suspension is no more than about 25 mg/mL, 30 mg/mL, 35mg/mL, 40 mg/mL, 45 mg/mL, 50 mg/mL, 55 mg/mL, 60 mg/mL, 65 mg/mL, 70mg/mL, 75 mg/mL, 80 mg/mL, or 85 mg/mL.

An ASBTI and a second active ingredient are used such that thecombination is present in a therapeutically effective amount. Thattherapeutically effective amount arises from the use of a combination ofan ASBTI and the other active ingredient (e.g., ursodiol) wherein eachis used in a therapeutically effective amount, or by virtue of additiveor synergistic effects arising from the combined use, each can also beused in a subclinical therapeutically effective amount, i.e., an amountthat, if used alone, provides for reduced effectiveness for thetherapeutic purposes noted herein, provided that the combined use istherapeutically effective. In some embodiments, the use of a combinationof an ASBTI and any other active ingredient as described hereinencompasses combinations where the ASBTI or the other active ingredientis present in a therapeutically effective amount, and the other ispresent in a subclinical therapeutically effective amount, provided thatthe combined use is therapeutically effective owing to their additive orsynergistic effects. As used herein, the term “additive effect”describes the combined effect of two (or more) pharmaceutically activeagents that is equal to the sum of the effect of each agent given alone.A syngergistic effect is one in which the combined effect of two (ormore) pharmaceutically active agents is greater than the sum of theeffect of each agent given alone. Any suitable combination of an ASBTIwith one or more of the aforementioned other active ingredients andoptionally with one or more other pharmacologically active substances iscontemplated as being within the scope of the methods described herein.

In some embodiments, the particular choice of compounds depends upon thediagnosis of the attending physicians and their judgment of thecondition of the individual and the appropriate treatment protocol. Thecompounds are optionally administered concurrently (e.g.,simultaneously, essentially simultaneously or within the same treatmentprotocol) or sequentially, depending upon the nature of the disease,disorder, or condition, the condition of the individual, and the actualchoice of compounds used. In certain instances, the determination of theorder of administration, and the number of repetitions of administrationof each therapeutic agent during a treatment protocol, is based on anevaluation of the disease being treated and the condition of theindividual.

In some embodiments, therapeutically-effective dosages vary when thedrugs are used in treatment combinations. Methods for experimentallydetermining therapeutically-effective dosages of drugs and other agentsfor use in combination treatment regimens are described in theliterature.

In some embodiments of the combination therapies described herein,dosages of the co-administered compounds vary depending on the type ofco-drug employed, on the specific drug employed, on the disease orcondition being treated and so forth. In addition, when co-administeredwith one or more biologically active agents, the compound providedherein is optionally administered either simultaneously with thebiologically active agent(s), or sequentially. In certain instances, ifadministered sequentially, the attending physician will decide on theappropriate sequence of therapeutic compound described herein incombination with the additional therapeutic agent.

The multiple therapeutic agents (at least one of which is a therapeuticcompound described herein) are optionally administered in any order oreven simultaneously. If simultaneously, the multiple therapeutic agentsare optionally provided in a single, unified form, or in multiple forms(by way of example only, either as a single pill or as two separatepills). In certain instances, one of the therapeutic agents isoptionally given in multiple doses. In other instances, both areoptionally given as multiple doses. If not simultaneous, the timingbetween the multiple doses is any suitable timing; e.g, from more thanzero weeks to less than four weeks. In addition, the combinationmethods, compositions and formulations are not to be limited to the useof only two agents; the use of multiple therapeutic combinations arealso envisioned (including two or more compounds described herein).

In certain embodiments, a dosage regimen to treat, prevent, orameliorate the condition(s) for which relief is sought, is modified inaccordance with a variety of factors. These factors include the disorderfrom which the subject suffers, as well as the age, weight, sex, diet,and medical condition of the subject. Thus, in various embodiments, thedosage regimen actually employed varies and deviates from the dosageregimens set forth herein.

In some embodiments, the pharmaceutical agents which make up thecombination therapy described herein are provided in a combined dosageform or in separate dosage forms intended for substantially simultaneousadministration. In certain embodiments, the pharmaceutical agents thatmake up the combination therapy are administered sequentially, witheither therapeutic compound being administered by a regimen calling fortwo-step administration. In some embodiments, two-step administrationregimen calls for sequential administration of the active agents orspaced-apart administration of the separate active agents. In certainembodiments, the time period between the multiple administration stepsvaries, by way of non-limiting example, from a few minutes to severalhours, depending upon the properties of each pharmaceutical agent, suchas potency, solubility, bioavailability, plasma half-life and kineticprofile of the pharmaceutical agent.

In certain embodiments, provided herein are combination therapies. Incertain embodiments, the compositions described herein comprise anadditional therapeutic agent. In some embodiments, the methods describedherein comprise administration of a second dosage form comprising anadditional therapeutic agent. In certain embodiments, combinationtherapies the compositions described herein are administered as part ofa regimen. Therefore, additional therapeutic agents and/or additionalpharmaceutical dosage form can be applied to a patient either directlyor indirectly, and concomitantly or sequentially, with the compositionsand formulations described herein.

Kits

In another aspect, provided herein are kits containing a device forrectal administration pre-filled a pharmaceutical composition describedherein. In certain embodiments, kits contain a device for oraladministration and a pharmaceutical composition as described herein. Incertain embodiments the kits include prefilled sachet or bottle for oraladministration, while in other embodiments the kits include prefilledbags for administration of rectal gels. In certain embodiments the kitsinclude prefilled syringes for administration of oral enemas, while inother embodiments the kits include prefilled syringes for administrationof rectal gels. In certain embodiments the kits include prefilledpressurized cans for administration of rectal foams.

Release in Distal Ileum and/or Colon

In certain embodiments, a dosage form comprises a matrix (e.g., a matrixcomprising hypermellose) that allows for controlled release of an activeagent in the distal jejunum, proximal ileum, distal ileum and/or thecolon. In some embodiments, a dosage form comprises a polymer that is pHsensitive (e.g., a MMX™ matrix from Cosmo Pharmaceuticals) and allowsfor controlled release of an active agent in the ileum and/or the colon.Examples of such pH sensitive polymers suitable for controlled releaseinclude and are not limited to polyacrylic polymers (e.g., anionicpolymers of methacrylic acid and/or methacrylic acid esters, e.g.,Carbopol® polymers) that comprise acidic groups (e.g., —COOH, —SO₃H) andswell in basic pH of the intestine (e.g., pH of about 7 to about 8). Insome embodiments, a dosage form suitable for controlled release in thedistal ileum comprises microparticulate active agent (e.g., micronizedactive agent). In some embodiments, a non-enzymatically degradingpoly(dl-lactide-co-glycolide) (PLGA) core is suitable for delivery of anASBTI to the distal ileum. In some embodiments, a dosage form comprisingan ASBTI is coated with an enteric polymer (e.g., Eudragit® S-100,cellulose acetate phthalate, polyvinylacetate phthalate,hydroxypropylmethylcellulose phthalate, anionic polymers of methacrylicacid, methacrylic acid esters or the like) for site specific delivery tothe ileum and/or the colon. In some embodiments, bacterially activatedsystems are suitable for targeted delivery to the ileum. Examples ofmicro-flora activated systems include dosage forms comprising pectin,galactomannan, and/or Azo hydrogels and/or glycoside conjugates (e.g.,conjugates of D-galactoside, β-D-xylopyranoside or the like) of theactive agent. Examples of gastrointestinal micro-flora enzymes includebacterial glycosidases such as, for example, D-galactosidase,β-D-glucosidase, α-L-arabinofuranosidase, β-D-xylopyranosidase or thelike.

The pharmaceutical solid dosage forms described herein optionallyinclude an additional therapeutic compound described herein and one ormore pharmaceutically acceptable additives such as a compatible carrier,binder, filling agent, suspending agent, flavoring agent, sweeteningagent, disintegrating agent, dispersing agent, surfactant, lubricant,colorant, diluent, solubilizer, moistening agent, plasticizer,stabilizer, penetration enhancer, wetting agent, anti-foaming agent,antioxidant, preservative, or one or more combination thereof. In someaspects, using standard coating procedures, such as those described inRemington's Pharmaceutical Sciences, 20th Edition (2000), a film coatingis provided around the formulation of the ASBTI. In one embodiment, acompound described herein is in the form of a particle and some or allof the particles of the compound are coated. In certain embodiments,some or all of the particles of a compound described herein aremicroencapsulated. In some embodiments, the particles of the compounddescribed herein are not microencapsulated and are uncoated.

An ASBT inhibitor may be used in the preparation of medicaments for theprophylactic and/or therapeutic treatment of cholestasis or acholestatic liver disease. A method for treating any of the diseases orconditions described herein in an individual in need of such treatment,may involve administration of pharmaceutical compositions containing atleast one ASBT inhibitor described herein, or a pharmaceuticallyacceptable salt, pharmaceutically acceptable N-oxide, pharmaceuticallyactive metabolite, pharmaceutically acceptable prodrug, orpharmaceutically acceptable solvate thereof, in therapeuticallyeffective amounts to said individual.

EXAMPLES

The following examples are provided to further describe some of theembodiments disclosed herein. The examples are intended to illustrate,not to limit, the disclosed embodiments.

Example 1. Phase 2 Open-Label Efficacy and Safety Study of the ApicalSodium-Dependent Bile Acid Transporter Inhibitor Maralixibat in Childrenwith Progressive Familial Intrahepatic Cholestasis (INDIGO ClinicalStudy)

The dosing regimen used in the INDIGO clinical study is summarized inFIG. 2. In addition to the doses indicated in FIG. 2, some patients wereadministered a dose of 280 μg/kg twice a day (BID) after initially beingadministered a dose of 280 μg/kg daily (QD). Dosing was escalated up to280 μg/kg QD over a period of 8 weeks.

Key inclusion criteria for the INDIGO clinical study were thefollowing: 1) aged 1-18 years; 2) clinically diagnosed with PFIC; 3) twomutant ABCB11 or ATB8B1 alleles. Key exclusion criteria for the INDIGOclinical study were the following: 1) surgically disrupted enterohepaticcirculation; 2) liver transplant; 3) decompensated cirrhosis.

The following cholestasis biomarkers were monitored in the INDIGOclinical study, among others: serum bile acid concentration (sBA); serumalanine aminotransferase (ALT) concentration; serum aspartateaminotransferase (AST) concentration; serum bilirubin concentration; andserum 7αC4 concentration. Fecal bile acid (fBA) concentration was alsomeasured. Severity of pruritus was assessed throughout the INDIGOclinical study using observer-reported itch-reported outcome(ITCHRO(OBS)) weekly average score (parent-rated e-diary) and clinicianscratch scale (CSS) score (investigator-rated). Patients were alsoadministered a health-related quality of life (HRQoL) assessmentthroughout the INDIGO clinical study. The HRQoL used was the PEDIATRICQUALITY OF LIFE INVENTORY (PedsQL). Multi-parameter response was definedby a greater than 70% reduction or normalization in sBA concentrationand a greater than 1.0 reduction or lower than 1.0 in ITCHRO(OBS) score.

Table 1 provides a summary of demographics and baseline health-relatedparameters for participants in the INDIGO clinical study. Of 25participants suffering PFIC 2, 19 participants had non-truncating ABCB11mutations (classified as mild or moderate) and 6 participants hadtruncating ABCB11 mutations, see Tables 2-3 and 5. 29 participantsreached week 48, see Table 4. Mild PFIC 2 was defined as PFIC 2resulting from a E297G or a D482G mutation to the ABCB11 gene whilemoderate PFIC 2 was defined as PFIC 2 resulting from an ABCB11 genecomprising missense mutations but not comprising a E297G or a D482Gmutation, see Table 3. Of the 19 participants having non-truncatingABCB11 mutations, 7 suffered mild PFIC 2 and 12 suffered moderate PFIC2, see Table 3 and Table 5. One patient (1 of 7 mild PFIC 2 patients)suffering mild PFIC 2 was a multi-parameter responder in the INDIGOclinical study at a dose of 280 μg/kg QD, see Tables 3, 4, and 6. Onepatient (1 of 12 moderate PFIC 2 patients) suffering moderate PFIC 2only demonstrated responsiveness (high-dose responder) after beingadministered a dose of maralixibat of 280 μg/kg twice daily (discussedfurther below), see Tables 3, 4, and 8. Five patients (5 of 12 moderatePFIC 2 patients) were responders in the INDIGO clinical study at a doseof 280 μg/kg/day by week 48 of the INDIGO clinical study, see Tables3-9. All PFIC 1 patients and all patients harboring a truncating ABCB11mutation were not multi-parameter responders in the INDIGO clinicalstudy, see Tables 3, 5 and FIG. 5.

Patients indicated as having no response in Table 3 demonstrated noresponse within the times and at the maximum dosages provided in Table6. Patients showing no response, therefore, may have demonstrated aresponse if administered maralixibat at a higher dose or for a longertime duration.

TABLE 1 Baseline disease characteristics and demographics forparticipants in the INDIGO clinical study Patient Characteristics PFIC1,n = 8 PFIC2, n = 25 N = 33 FIC1 def. BSEP def. Median Age 2.0 (1-7) 4.0(1-13) (range), year Boys, n (%) 6 (75) 8 (32) White, n (%) 6 (75) 20(80) Serum bile acid 261.9 (159.8-423.5) 381.0 (34.4-602.1) (range)μmol/L Mean (SD) z = scores Height −2.96 (1.47) −1.29 (0.98) Weight−2.70 (2.82) −0.63 (0.88)

TABLE 2 Genetic status of participants in the INDIGO clinical studyhaving PFIC 2 BSEP Genetic Status Participants (n) Non-truncating 19(mild/moderate) Truncating 6

TABLE 3 ABCB11 genotypes, PFIC 2 classifications, and observed responsesfor PFIC 2 participants in the INDIGO clinical study Mutation 1 Mutation2 Subject ID cDNA Protein cDNA Protein Classification Response001051-J-D c.149T > C Leu50Ser c.3667G > A Glu1223Lys Moderate Noreponse 001053-M-E c.890A > G Glu297Gly c.890A > G Glu297Gly Mild Noreponse 001054-LOA c.2495G > A Arg832His c.2842C > T Arg948Cys ModerateRapid complete response 001055-H-B c. 2611-2 A > T Splice site c. 2611-2A > T Splice site Severe No reponse 001057-W-R c.319T > C Cys107Argc.319T > C Cys107Arg Moderate No reponse 001060 c.319T > C Cys107Argc.319T > C Cys107Arg Moderate No reponse 002052-M-H c.1145-1165delp.Ala382_Ala388del c.2787_2788insGAGAT p.Lys930Glufs*79 Severe Noreponse 002053-E-B c.499G > A p.A167T c.3457G > A p.R1153S Moderate Noreponse 002054-KRD c.149T > C p.L50S c.890A > G p.E297G Mild No reponse003052-R-C c.890A > G Glu297Gly c.2012-8T > G Splice site Mild Noreponse 003053-A-J c.890A > G Glu297Gly c.2842C > T Arg948Cys Mild Noreponse 013051-T-C c.403G > A E135K c.1012-8T > G Splice site ModerateNo reponse 013052-JMC C.1408C > T p.R470* c.3945delC p.T1316Lfs*64Severe No reponse 014051 c.1460G > C p.(Arg487Pro) c.2944G > Ap.(Gly982Arg) Moderate No reponse 016051---- c.470A > G p.Y157Cc.3892G > A p.G1298R Moderate Rapid complete response 016052----c.470A > G p.Y157C c.3892G > A p.G1298R Moderate Rapid complete response016053---- c.757G > A Gly253Arg c.1769A > G Asp590Gly Moderate Goodresponse 016054---- c.2783_2787dupGAGAT Lys930Glufs*79 c.1769A > GAsp590Gly Moderate No response until 560 reached 027051-T-S c.3457C > TArg1153Cys c.3476T > C Val1159Ala Moderate Rapid complete response027052-AJC c.890A > G Glu297Gly c.3491delT Val1164Glyfs7 Mild No reponse027053-VJB c.890A > G Glu297Gly c.890A > G Glu297Gly Mild No reponse052051-S-C c.1826_1827insCA Ile610fs c.1826_1827insCA Ile610fs Severe Noreponse 052052-S-M c.1827_1828insCA Ile610fs c.1827_1828insCA Ile610fsSevere No reponse 052054 c.1062T > A Tyr354Ter 1052T > A Tyr354TerSevere No reponse 080051-L-M c.1558A > T p.(Arg520Ter) c.1445A > Gp.Asp482Gly Mild >70% reduction in BAs

TABLE 4 Disposition of patients in the INDIGO study to week 48 Reachedweek 48, n 29 Efficacy data available, n 26 PFIC1 6 PFIC2 20 Maralixibatdose, n 280 μg/kg/day 23 140 μg/kg/day 2 <140 μg/kg/day^(a) 1 ^(a)Onepatient receiving 280 μ/kg/day had a treatment interruption and wasre-escalated at week 48

TABLE 5 Summary of subject PFIC genotype status for responders in theINDIGO clinical study Subject Genotype Status Multi-parameter RespondersNon-truncating BSEP (N = 19) 7/19 (36.8%) Mild (N = 7) 1/7 (14.3%)Moderate (N = 12) 6/12 (50%) Truncating BSEP (N = 6) 0/6 (0%)

TABLE 6 Study duration and max dose for participants in the INDIGOclinical study Subject ID Max dose Study duration 001051-J-D 280 72weeks 001053-M-E 280 72 weeks 001054-LOA 280 1328 days 001055-H-B 280124 weeks 001057-W-R 560 1247 days 001060 280 60 weeks 002052-M-H 280 86weeks 002053-E-B 280 60 weeks 002054-KRD 280 72 weeks 003052-R-C 280 72weeks 003053-A-J 560 1127 days 013051-T-C 280 60 weeks 013052-JMC 280122 weeks 014051 280 60 weeks 016051— 280 1218 days 016052— 280 1218days 016053— 560 1196 days 016054— 560 927 days 027051-T-S 280 1220 days027052-AJC 280 72 weeks 027053-VJB 280 72 weeks 052051-S-C 280 72 weeks052052-S-M 280 72 weeks 052054 280 72 weeks 080051-L-M 560 924 days

TABLE 7 Summary of efficacy measures at baseline and changes at week 48of the INDIGO clinical study Total sBA, ALT, bilirubin, C4, ItchRO(Obs)PedsQL μmol/L UI/L mg/dL ng/mL score total score Baseline, mean (range)352 108  2.9  4.2  2.3 61.5 (34, 602)  (13, 438)  (0.1, 15.1) (0.1,47.3) (0.1, 3.8) (18.1, 85.9)  Change from baseline to week 48, mean(95% CI) −32 −12 +0.8 +6.0 −1.0 +8.2 (−110, +46) (−36, +13) (−0.1, +1.7)(−0.6, +12.5) (−1.4, −0.6) (+0.7, +15.6)

TABLE 8 Summary of responders observed in PFIC patients thatparticipated in the INDIGO clinical study (n = 6) by week 48 Diagnosis,n PFIC1 (ATP8B1 mutation) 0 PFIC2 (ABCB11 mutation) 6 Reached week 48, n6 Maralixibat dose, n 280 μg/kg/day 6

TABLE 9 Overview of responses observed in responders in the INDIGOclinical study (n = 6) by week 48 sBA levels, n Normalized (±≤8.5μmol/L) 4 Reduced by ≥70% or ≥80% from baseline 2 ItchRO score, n Zero(no pruritus) 2 Improved by ≥1.0 points from baseline 4

Therefore, in view of the above observations, patient responsiveness toadministration of maralixibat correlated with patient genotype. Inparticular, the INDIGO clinical study revealed the surprising resultthat only patients suffering PFIC 2 caused by a non-truncating ABCB11gene mutation were responders to administration of maralixibat.Additionally, it was unexpectedly found that moderate PFIC 2 patientswere more likely to show a response at 280 μg/kg/day of maralixibat thanmild PFIC 2 patients, see Tables 3 and 5-6.

The six patients demonstrating a response at 280 μg/kg/day ofmaralixibat (low-dose responders) demonstrated a decrease in sBAconcentration, serum ALT concentration, serum bilirubin concentration,ITCHRO(OBS) score, and PEDSQL score and increase in serum 7αC4 (C4)concentration by week 48 of the INDIGO clinical study, see Table 7. Twoof the low-dose responders demonstrated a reduction in sBA from baselineof over 70% or over 80%, see Table 9. Four of the low-dose respondersdemonstrated a normalization in sBA, see Table 9. A detailed overview ofeach of the six low-dose responders to maralixibat administration isprovided as FIG. 3. All low-dose responders demonstrated an increase inC4 levels of at least 2.5-fold relative to baseline within 13 weeks offirst administration of maralixibat in the INDIGO clinical study. Alllow-dose responders demonstrated establishment of normalized or onlymildly elevated concentrations of serum ALT, AST, and bilirubinconcentrations over time (e.g., within 2-6 months of firstadministration of maralixibat) in the INDIGO clinical study.

Gastrointestinal infections were found to interfere with of thetreatment effect of maralixibat in PFIC 2, see FIGS. 3D and 3E.Therefore, gastrointestinal infections may cause otherwise responsivepatients to appear non-responsive to administration of maralixibat.

Three patients that did not demonstrate a response at a dose of 280μg/kg/day of maralixibat non-truncating PFIC 2 were administered 560μg/kg/day of maralixibat and one (mentioned above) responded at thehigher dose, see Tables 3 and 6.

The low-dose responders demonstrated 7αC4 concentrations at 48 weeksthat were 14× baseline (range, 3-43). Non-responder 7αC4 concentrationswere 1.8× baseline (range, 0.5-6) at 48 weeks. This demonstrates acorrelation between response and increased BA synthesis. The mean changefrom baseline at week 48 in the ratio of 7αC4 concentration to sBAconcentration (7αC4:sBA) for the low-dose responders was 1388 timesbaseline ratio (range, 5-3982), whereas the ratio was 1.9 times baselineratio (range, 0.43-12) in non-responders. The high-dose responderdemonstrated a 7αC4:sBA ratio of 12 times baseline prior toadministration of 560 μg/kg/day of maralixibat, which increased to 1770times baseline upon administration of the higher dose.

Not wishing to be limited by any particular mechanism of action,patients with greater retained canicular transport (as in the mild PFIC2 patients) may require higher doses of maralixibat to block absorptionof BA than those patients with lower retained canicular transport.Further, patients with biochemical effect (increase in 7αC4:sBA ratio)but not clinical response may be rescued with higher maralixibat doses.

A further surprising result was observed in the INDIGO clinical study.Low-dose responders demonstrated improved growth relative to baseline,whereas non-responders did not, see FIG. 4. Improved growth was measuredusing height Z-score and was defined as a positive height Z-score changerelative to baseline height Z-scores measured prior to administration ofmaralixibat. Furthermore, the high dose responder also exhibited anincrease in height Z-score following treatment response on sBA.

Twelve patients participated in a long-term extension of the INDIGOclinical study. FIGS. 5-8 plot measurements of cholestasis markers takenfor all participants in the INDIGO clinical study over time. Thehigh-dose responder was first administered a daily dose of 560 μg/kg/day(2 equal doses of 280 μg/kg daily, BID) at between 547 and 638 days, seeFIG. 5A. The high-dose responder demonstrated an increase in 7αC4:sBAratio following administration of the higher dose, see FIG. 8. Alow-dose responder demonstrating an increase in sBA concentration, adecrease in serum 7αC4 concentration, and a decrease in 7αC4:sBA ratioduring the long-term extension was administered a higher dose ofmaralixibat (280 μg/kg BID) at between 640 and 730 days, see FIGS. 5Aand 6-8. Following the administration of the higher dose, sBAconcentration decreased, severity of pruritus decreased, serum 7αC4concentration increased, and 7αC4:sBA ratio increased, see FIGS. 5A and6-8. One low-dose responder demonstrated an increase in sBA during thelong-term extension and was therefore administered a higher dose ofmaralixibat (280 μg/kg BID) at between 820 and 910 days, see FIG. 6. Theseverity of pruritus subsequently decreased, see FIG. 6, and the7αC4:sBA ratio increased, see FIG. 8.

In the long-term extension of the INDIGO clinical study, no patientshaving an ABCB11 gene with a truncating mutation were responders, seeFIG. 5B.

One non-responder demonstrated an initial increase in 7αC4:sBA ratiobefore 90 days, which subsequently decreased, see FIG. 8. Thisnon-responder may have demonstrated a response if the non-responder hadbeen administered a higher dose of maralixibat (e.g., 280 μg/kg BID)prior to being withdrawing from the INDIGO clinical study. The initialincrease, or spike, in 7αC4:sBA ratio indicates that this patient mayhave been capable of demonstrating a response (i.e., a clinicalresponse) to maralixibat administration.

Responders in the INDIGO study maintained a response to maralixibat forover a year and for up to or beyond 5 years, see FIGS. 5-8. Patientswith non-truncating BSEP deficiency demonstrated durable control ofpruritus and cholestasis with maralixibat, see FIGS. 5-8. FIGS. 5-8demonstrate that 7αC4:sBA ratio is a good predictor of response toASBTI.

Responders had genotypes consistent with residual BSEP function, whereassome non-responders had genotypes consistent with total lack of BSEPfunction.

Example 2. Dose-Dependent Fecal Bile Acid Excretion with ApicalSodium-Dependent Bile Acid Transporter Inhibitors Maralixibat andVolixibat in a Dose-Ranging Phase 1 Clinical Study (NTC02475317) inOverweight and Obese Adults

Multiple oral doses of maralixibat, volixibat, or placebo wereadministered once (QD) or twice (BID) for 7 days in overweight and obeseadults on a low-fiber diet. Participants had a body mass index of from25 kg/m² to 35 kg/m². Participants consumed a low-fiber diet (<10mg/day) for 2 days before randomization and during the 7-day treatmentperiod. Measurements were taken of fBA, sBA concentration, and serum7αC4 concentration (which is a biomarker of bile acid synthesis) priorto drug administration and at day 7.

A summary of demographics and baseline fBA for participants to whicheach drug at each indicated dosage was administered is provided in Table10. Overall demographics for all patients participating in the study arealso provided in Table 10.

TABLE 10 Summary of demographics and baseline characteristics forparticipants in a phase 1, blinded, placebo-controlled, dose-rangingclinical study (NCT02475317). BID, twice daily; QD, once daily; SD,standard deviation; n, number of participants; multiple = mixed race(black and white). Maralixibat Placebo 10 mg QD 20 mg QD 50 mg QD 100 mgQD 50 mg BID n 14 10  10  10  10  10  Mean age, 38.2 (9.32) 45.4 (11.18)32.2 (8.92) 36.4 (12.87) 38.5 (9.87) 39.4 (12.66) year (SD) Race, n (%)White 7 (50.0) 6 (60.0) 3 (30.0) 7 (70.0) 7 (70.0) 6 (60.0) Black 6(42.9) 4 (40.0) 7 (70.0) 3 (30.0) 3 (30 0) 4 (40.0) Black & 1 (7.1) 0 00 0 0 White Mean fBA 246.44 (113.597) 200.91 (176.918) 138.46 (91.660)192.40 (235.828) 230.39 (231.489) 199.31 (147.859) excretion, μmol (SD)Maralixibat Volixibat All doses 10 mg QD 20 mg QD All doses Overall n50  10  10   20 84  Mean age, 38.4 (11.58) 37.5 (6.74) 43.7 (14.40) 40.6(11.39) 38.9 (11.11) year (SD) Race, n (%) White 29 (58.0) 6 (60.0)515201 11 (55.0) 47 (56.0) Black 21 (420) 4 (40.0) 4 (40.0) 8 (40.0) 35(41.7) Black & 0 0 1 (10.0) 1 (5.0) 0 White Mean fBA 160.91 (129.561)263.19 (287.653) excretion, μmol (SD)

Of 84 participants, 50 were randomized to maralixibat, 20 to volixibat,and 14 to placebo, see Table 10. All participants completed the study.Mean baseline fBA excretion ranged from 138 μmol to 240 μmol (SD,92-231) across maralixibat doses and 161 μmol to 263 μmol (SD, 130-288)across volixibat doses and was 246 μM (SD, 114) for placebo, see Table10.

fBA excretion increased in a dose-dependent manner for maralixibat andvolixibat, with no notable change for placebo, see FIG. 9. Mean changefrom baseline was similar at the highest maralixibat doses: 1251 μmol(95% confidence interval, 539-1963) for 50 mg BID and 1144 μmol (95%confidence interval, 823-1466) for 100 mg QD, see FIG. 9. At the 10 mgdose for maralixibat and volixibat, mean change from baseline was 515μmol (95% confidence interval, 196-835) and 744 μmol (95% confidenceinterval, 230-1257), respectively, see FIG. 9. At the 20 mg dose formaralixibat and volixibat, mean change from baseline was 532 μmol (95%confidence interval, 60-1005) and 874 μmol (95% confidence interval,457-1290), respectively, see FIG. 9.

Mean serum 7αC4 increased with administration of maralixibat orvolixibat, with the greatest change observed at a maralixibat dose of 50mg BID, see FIG. 10.

No notable change in sBA or 7αC4 was observed with placebo, see FIGS.9-10. Mean baseline sBA levels were not elevated with administration ofmaralixibat or volixibat but did increase by 2.6 ng/mL (95% confidenceinterval, 1.2-3.9) with placebo. All treatment-emergent adverse eventswere mild, and none were serious. The proportion of participants withtreatment-emergent adverse events did not differ among volixibat andmaralixibat doses, or between maralixibat and volixibat. The onlytreatment-emergent adverse events occurring in over 10% of participantswere headache and diarrhea.

Increases in fBA excretion were dose-dependent up to the maximum testeddoses of volixibat and maralixibat, see FIG. 9. Safety outcomes weresimilar across tested dose ranges and between compounds.

At the highest daily doses of maralixibat, increases in fBA excretionwere numerically higher with 50 mg BID than with 100 mg QD, see FIG. 9.

Example 3. Safety and Efficacy of Maralixibat in Participants withPrimary Sclerosing Cholangitis (PSC): a 14-Week, Single-Arm, Open-Label,Phase 2a, Proof-of-Concept Study of Maralixibat (the CAMEO ClinicalTrial; Clinical Trials.gov: NTC02061540)

The CAMEO clinical trial included a 6-week dose-escalation period(maralixibat 0.5 mg/day, 1 mg/day, 2.5 mg/day, 5 mg/day, and 7.5 mg/day)followed by an 8-week dose-maintenance period (maralixibat 10 mg/day)and a 4-week follow-up period.

Participants were adults aged 18-80 years with a diagnosis of PSC. PSCdiagnosis included a documented history of alkaline phosphatase (ALP)levels greater than 1.5 times above the upper limit of normal, biliaryobstruction, and histological findings consistent with PSC diagnosis (ifpreviously biopsied). The study enrolled 27 adults.

Efficacy was assessed by measuring at baseline and throughout the studysBA concentration, serum 7αC4 concentration (a marker of de novo bileacid synthesis), serum aoutotaxin concentration, LDL-C concentration,serum total cholesterol concentration, serum liver enzymeconcentrations, and pruritus severity. Pruritus severity was determinedby calculating Adult Itch Reported Outcome (ITCHRO) weekly sum scoresand average daily scores (mean score over a 7-day period). Participantsself-reported the ITCHRO daily on a scale 0-10 (0=no pruritus; 10=mostsevere pruritus).

Baseline mean serum alkaline phosphatase concentration for participantsin the CAMEO study was 471.6 U/L (SD, 316.9).

Outcomes were assessed in the overall study population and in subgroupsof participants (A) with any pruritus at baseline or (B) with an ITCHROaverage daily score ≥4 out of 10 at baseline. Efficacy endpoints werebased on change from baseline to week 14 or early termination (ET) andwere analyzed using paired t-tests or Wilcoxon signed rank tests.

Of 27 enrolled participants, 23 (85.2%) completed the study.Participants were predominantly male (66.7%) and white (85.2%), with amean age of 43.7 years (standard deviation [SD], 11.35) at studyenrollment. Mean time since PSC diagnosis was 94 months (SD, 75.4). PSCsymptoms of inflammatory bowel disease and ulcerative colitis werereported by 44.4% and 55.6% of participants, respectively.

ITCHRO weekly sum scores decreased from baseline by 51% (p=0.0495)overall, by 53% (p=0.0275) in participants with any pruritus at baseline(n=18), and by 70% (p=0.0313) in participants with an ITCHRO daily score≥4 out of 10 at baseline (n=6), see FIG. 11. ITCHRO average daily scoreimproved by >3 points in 6 of 27 (22.2%) participants and improved by >1point in 8 out of 27 (29.6%) participants. No participants experiencedworsening of pruritus by >1 point from baseline to week 14. Pruritusimproved in all 6 participants with an ITCHRO score ≥4 at baseline, seeTable 11 and FIG. 11.

TABLE 11 ITCHRO scores for participants in the CAMEO clinical study withan ITCHRO daily score ≥4 at baseline ItchRO average daily score (0-10scale) Week Change from baseline Participant Baseline 14/ET to week14/ET A 9.1 0 −9.1 B 4.7 0 −4.7 C 5.9 1.3 −4.6 D 6.9 5.1 −1.7 E 6.9 3.1−3.7 F 6.0 2.3 −3.7 ET, early termination; ItchRO, Itch ReportedOutcome.

sBA levels decreased from baseline by 38% (mean −14.8 μmol/L [SD, 31.4];p=0.0043) overall and by 45% in participants with an ITCHRO daily score≥4 at baseline, see FIG. 12. Mean levels of 7αC4 increased from baselineby 130% (mean, 11.1 ng/mL [SD, 13.6]; p<0.0001) overall and by 107% inparticipants with an ITCHRO daily score ≥4 at baseline, see FIG. 12.

In the overall population of participants in the CAMEO clinical trial,significant reductions were observed in serum autotaxin concentration(−148 ng/mL [SD, 319]; p=0.0462) and serum LCL-C concentration (−16.3mg/dL [SD, 17.6]; P<0.0001), see FIG. 13. In participants with an ITCHROdaily score ≥4 at baseline, significant reductions were observed inautotaxin levels, see FIG. 13. Reductions were observed in levels oftotal cholesterol in the overall population (mean change, −21.2 mg/dL[SE, 4.90; SD, 25.5]; p=0.0002) and in participants with an ITCHRO dailyscore ≥4 at baseline (mean change, −32.0 mg/dL [SE, 13.38]; p=0.06).

Mean conjugated bilirubin levels increased by 0.19 mg/dL (SE, 0.09,p<0.0462; SE, 0.450) in the overall population, with no significantchange in participants with ITCHRO daily score ≥0 at baseline. Changesin serum total bilirubin, alanine aminotransferase, aspartateaminotransferase, and alkaline phosphatase concentrations were notstatistically significant in participants in the CAMEO clinical study.

Statistically significant reductions in pruritus and sBA were observedafter 14 weeks of treatment with maralixibat in the CAMEO clinicalstudy, which is consistent with a proposed mechanism of action formaralixibat, see FIG. 1. Levels of serum autotaxin, a potential markerfor cholestatic pruritus, also improved in a statistically significantmanner, see FIG. 13. Mean percent reductions were greater in pruritusand sBA and autotaxin levels in participants with an ITCHRO daily score≥4 at baseline than in the overall participant population for the CAMEOstudy, see FIG. 14.

Statistically significant reductions in serum LDL-C levels andstatistically significant increases in serum 7αC4 levels indicated denovo synthesis of bile acids from cholesterol, which is consistent withASBT inhibition.

Maralixibat was well tolerated in the CAMEO study and associated withreduced serum BA levels in adults with PSC. In addition, autotaxinlevels reduced and pruritus improved significantly from BL, with thegreatest reductions in those with worst pruritus at baseline.

Example 4. Durability of Treatment Effect with Long-Term Maralixibat inChildren with Alagille Syndrome: 4-Year Efficacy Results from a Phase 2bDouble-Blind, Randomized, Placebo-Controlled Drug-Withdrawal Study witha Long-Term Open-Label Pretreatment Period of Maralixibat 400 μm/kW/DayTwice Daily (BID) (the ICONIC Clinical Study)

Children aged 1-18 years with a diagnosis of ALGS and evidence ofcholestasis were eligible to enroll in the ICONIC clinical study, seeTables 12-14. During a long-term extension, participants with sBA levelsabove the upper limit of normal and/or an ITCHRO(OBS) score >1.5 wereeligible for the 400 μg/kg BID dose (all participants received the 400μg/kg BID dose). Inclusion criteria for the ICONIC study included havingcholestasis, which was defined as at least one of 1) sBA concentration(total sBA) >3× the upper limit of normal, 2) serum conjugated bilirubinconcentration >1 mg/dL, 3) fat-soluble vitamin deficiency not otherwiseexplained, 4) serum gamma-glutamyl transferase concentration >3× theupper limit of normal, and 3) intractable pruritus explainable only byliver disease. Inclusion criteria also included having significantpruritus, which was defined as an average daily score of >2 on theITCHRO(OBS) scale for 2 consecutive weeks (0=no pruritus; 4=most severepruritus). Exclusion criteria included having surgically disruptedenterohepatic circulation, a liver transplant, decompensated cirrhosis,or having any liver disease other than ALGS.

TABLE 12 Disposition and demographics for participants in the ICONICclinical study. Disposition and demographics Median Age (range), years5.4 (1-15) Male, % 61.3 Genotype, n (%) JAG1 31 (100) Enrolled, n 31Randomized week 18, n 29 Maralixibat 13 Placebo 16 Completed week 48, n28

TABLE 13 Baseline characteristics for participants in the ICONICclinical study. Baseline characteristics, mean (SD) ItchRO (Obs), 0-42.9 (0.5) CSS, 0-4 3.3 (0.9) sBA, μmol/L 283 (211) C4, ng/mL 10.3 (14.7)Total bilirubin, mg/dL 6.1 (5.8) Direct bilirubin, mg/dL 4.6 (3.7) ALT,U/L 181 (109) Clinician xanthoma scale, 0-4 0.9 (1.26) PedsQL, 0-10061.2 (17.3) ALT, alanine transaminase.

sBA responders were defined as those patients achieving ≥50% reductionfrom baseline in sBA at week 12 or 18. ITCHRO responders were defined asthose patients achieving at least a 1-point reduction from Baseline inweekly morning ITCHRO(OBS) score at week 12 or 18.

A summary of the experimental design for the ICONIC clinical study isprovided as FIG. 15. After completion of the 48-week core study at adose of 400 μg/kg daily (QD), participants were able to continuelong-term treatment with maralixibat 400 μg/kg QD (the extension portionof the study). In the open label extension, the effect of higher doseswas explored by increasing dosage to a maximum of 400 μg/kg BID ineligible participants.

Efficacy assessments were based on changes from baseline in sBAconcentration, weekly average ITCHRO(OBS) scores (0, none; 4, mostsevere), CSS score (0, none; 4 most severe), and Clinician XanthomaScale score (0, none; 4, disabling). During a randomized withdrawalperiod (week 18-22), differences between maralixibat and placebo in sBAconcentration and ITCHRO(OBS) scores were evaluated. During thelong-term extension, efficacy assessments were conducted every 12 weeks.Serum total cholesterol and serum 7αC4 concentration were also monitoredduring the ICONIC clinical study, among other measures.

sBA were measured using a fully validated liquidchromatography-electrospray ionization-mass electrospray (LC-ESI-MS)method using stable-isotope dilution analysis to measure serumconcentrations of principal bile acids (cholic, chenodeoxycholic,ursodeoxycholic, deoxycholic acid, lithocholic, and their correspondingglycine and taurine conjugates). Serum samples were analyzed in theDivision of Pathology and Laboratory Medicine, Cincinnati Children'sHospital Medical Center according to SOP # PATH.CMS.1033. Calibrationstandards of individual bile acids were in the range of 50-25,000 ng/mLand Quality Control samples were prepared at concentrations of 100, 500,1000, 2500, and 20000 ng/mL. The intra- and inter-assay imprecision ofthe method for individual bile acids measured was within the acceptedGLP quality assurance guidelines of <15% coefficient of variance forthese QC samples. The lower limit of quantification of the assay was setat 100 ng/mL and the imprecision at this concentration was <20%. Thelimit of detection of the assay was 5 ng/mL. Total sBA is represented bythe sum of the individual bile acid species measured.

Of the 28 participants who completed the core study (up to week 48), 23consented to long-term extension. After 2 years, 15 participantscontinued in the extension phase with a dose increase to 400 μg/kg BID,see FIGS. 15-16. Table 14 provides baseline characteristics anddemographics for participants in the long-term extension.

TABLE 14 Baseline characteristics and demographics for participantsenrolled in the ICONIC clinical study and participants in the long-termextension of the ICONIC clinical study Enrolled Extension participantsparticipants (N = 31) (N = 15) Median age (range), years 5.0 (1-15) 5.0(1-12) Male, n (%) 19 (61.3) 10 (66.7) JAG1 mutation, n (%) 31 (100.0)15 (100.0) Serum bile acid level, μmol/L 283.4 (37.8) 259.0 (55.3) TotalBilirubin mg/dL 6.1 (1.0) 3.2 (0.9) ItchRO(Obs) score (0-4) 2.9 (0.1)2.8 (0.1) CSS score (0-4) 3.3 (0.2) 3.2 (0.3) Height z-score −1.7 (0.2)−1.8 (0.3) Data presented as mean (SE) unless otherwise specified.

sBA concentration decreased by 31% (p=0.0005) during the first 18 weeksof treatment with maralixibat at 400 μg/kg QD, see FIGS. 17-18 and 32.During randomized withdrawal, sBA levels returned to baseline in theplacebo group but were maintained in the maralixibat groups (leastsquares [LS] mean difference, −114.0; SE, 48.0; p=0.03), see FIGS. 17-18and 32. Reductions in sBA levels were maintained and continued toimprove during the long-term extension, see FIGS. 18 and 19. At 191weeks, sBA levels were reduced by about 57% from baseline (p=0.0047),see FIG. 19.

Serum total cholesterol concentration and serum 7αC4 concentration bothshowed a statistically significant decrease from baseline by week 48 andweek 191, see Table 15. A statistically significant decrease observed inserum total cholesterol concentration and serum 7αC4 concentrationobserved by week 49 was maintained through week 191 of the ICONICclinical study, see Table 15.

TABLE 15 Serum cholesterol concentration (mg/dL) and serum 7αC4concentration (ng/mL) at baseline, week 48, and week 191 and acomparison of the week 49 and week 191 measurements to the baselinemeasurements for participants in the ICONIC clinical study. MeanBaseline Week 48 Week 191 (SD) n = 15 n = 15 n = 15 Serum cholesterol,mg/dL 414.3 340.3 277.5 (182.1) (149.9) (65.7) p value^(a) <0.01 <0.01C4, ng/mL  7.4 20.4 30.4  (8.7) (32.2) (44.6) p value^(a) 0.1 0.04

ITCHRO(OBS) scores decreased from baseline (mean change, −1.7; SE, 0.2;p<0.0001) during the first 18 weeks of treatment with maralixibat at 400μg/kg QD, see FIGS. 20, 23 and 32. During randomized withdrawal,pruritus worsened in the placebo group but not in the maralixibat group(LS mean difference, −1.5; SE, 0.3, p=0.0001), see FIGS. 20, 21, 23, 25and 32 and Table 16. At 191 weeks, ITCHRO(OBS) score was reduced frombaseline (mean change, −2.5; SE, 0.2; p<0.0001), see FIGS. 22-23.Improvement in pruritus was also demonstrated by a mean reduction in CSSscore at 191 weeks of 2.4 points (SE, 0.4; p<0.0001), FIG. 22, and amean reduction in ITCHRO(OBS) score at 193 weeks of over 2 points to afinal score of about 0.33 (SE, 0.2; p<0.0001), see FIGS. 23 and 24.Also, CSS scores decreased by over 1.5 points (final average score ofabout 1.5) on average by week 48 across all participants, FIG. 22, andITCHRO(OBS) scores decreased by over 1.5 points on average (finalaverage score of about 0.33) relative to baseline by week 193, see FIGS.23 and 24. Control of pruritus improved over time, with over 89% ofstudy days across participants reported by observers as minimal or nopruritus (ITCHRO(OBS)≤1) after 98 weeks, see FIGS. 21-25.

TABLE 16 A greater proportion of ITCHRO(OBS) responders were observed ina maralixibat group than placebo during withdrawal in the ICONICclinical study ItchRO (Obs) Open-label Withdrawal - Week 22 Open-labelresponder criteria Week 18 Maralixibat Placebo Week 48 Decrease from67.7% 53.8% 25.0% 72.4% baseline ≥1 (p = 0.14)  Decrease from 58.1%46.2% 12.5% 58.6% baseline ≥1.25 (p = 0.09)^(a) Decrease from 51.6%23.1%   0% 51.7% baseline ≥1.5 (p = 0.01)^(a)

Reductions in sBA concentration and pruritus severity continued and werefurther improved during the extension, see FIGS. 18-19 and 22-24, andxanthomas continued to be re-absorbed (p<0.05), see FIG. 29. CSS scorescontinued to improve during the extension (p<0.0001). Improvements wereseen in PedsQL Multidimensional Fatigue Scale scores (p<0.01) during theICONIC core study and extension, see FIGS. 26-27. Therefore, maralixibatimproved quality of life.

Clinician Xanthoma Score was reduced by 0.7 points (SE, 0.3; p=0.0285)from baseline in participants in the ICONIC clinical study by week 191.Clinician xanthoma scale scores improved significantly (p<0.01) acrossall participants by week 48, see FIG. 28. Xanthomas continued to bereabsorbed during the long-term extension, see FIG. 29. Thus,maralixibat improved xanthomas.

Maralixibat was well tolerated during the core study and extension ofthe ICONIC clinical study for a period of over three years. Treatmenteffect was maintained over a period exceeding 48 weeks. Serumconcentrations of GGT, ALT, AST, and bilirubin were monitored throughoutthe ICONIC clinical study, see FIG. 30.

Therapeutic benefits of maralixibat in children with ALGS wereclinically relevant and statistically significant. Continuation ofmaralixibat treatment following a withdrawal period maintainedsignificantly lower sBA levels and less severe pruritus than placeboduring the randomized placebo-controlled drug-withdrawal period.Maralixibat significantly reduced pruritus and sBA levels over time andversus placebo in children with ALGS. Long-term maralixibat treatmentwas associated with durable control of sBA levels, pruritus, andxanthomas, as well as improved growth (discussed further below).Maralixibat was generally well tolerated at doses up to 800 (g/kg/dayand with treatment duration up to 4 years.

A positive correlation was observed between reduction in sBAconcentration and reduction of severity of pruritus as measured by theITCHRO(OBS) scale, see FIGS. 31-32 and Tables 17-19.

TABLE 17 ITCHRO(OBS) weekly morning average score by sBA responsedefinition for participants in the ICONIC clinical study. A reduction insBA concentration showed a positive correlation with a reduction inITCHRO(OBS) weekly morning average score, as compared to baseline.ItchRO(Obs) Weekly Morning Average Score Week 48 Week 48 Average sBAResponse (N = 28) Average Change from Definition n (%) Score Baseline≥50% Reduction 13 (46.4%) 1.07 −1.86 ≥60% Reduction 11 (39.3%) 0.82−2.12 ≥70% Reduction 8 (28.6%) 0.62 −2.31 ≥80% Reduction 4 (14.3%) 0.11−2.79 ≥90% Reduction 1 (3.6%) 0.00 −2.71 Normalization 1 (3.6%) 0.00−3.50 (<8.5 μmol/L)

TABLE 18 sBA concentrations and change in ITCHRO(OBS) weekly morningaverage score from baseline for participants (subjects) in the ICONICclinical study at week 48. Serum Bile Acid (μmol/L) Change from Changein ItchRO Baseline from Baseline Subject ID Baseline Week 48 to Week 48to Week 48 001021 79.4 22.9 −56.4 −0.12 001022 298.1 131.8 −166.3 0.49001023 379.9 98.5 −281.4 −0.45 040001 411.8 578.1 166.4 1.29 040002^(a)503.2 040003 142.0 20.8 −121.1 −3.86 050001 328.7 333.0 4.3 0.00 050003370.5 119.6 −251.0 −2.57 050004 114.5 117.7 3.3 −0.86 050005 519.9 492.6−27.3 −0.71 050006 583.4 427.9 −155.5 −0.00 050007 440.0 199.8 −240.2−0.29 051001 20.2 29.2 9.0 −0.67 051002 748.5 891.6 143.1 −0.14 052002275.6 163.4 −112.2 −0.71 060001 43.8 60.2 16.4 −0.03 060002 22.8 12.0−10.9 −3.29 060003 40.5 23.6 −16.9 −3.43 060004 71.6 126.1 54.5 −2.50061001 657.4 37.0 −620.4 −2.71 061002 30.9 7.0 −23.9 −3.50 061004 479.2101.9 −377.3 −3.29 061005 499.2 293.3 −205.9 −0.00 061006 335.4 65.0−270.4 −2.71 080001 85.4 110.9 25.5 −2.29  80003 239.4 35.8 −203.6 −0.86090001 203.7 208.0 4.3 −0.17 090002 152.2 55.8 −96.4 −0.43 090003 49.515.6 −33.9 −0.83 090004^(a) 496.9 090005^(a) 162.8 ^(a)Subjects do nothave data beyond baseline due to early discontinuations prior to Week48.

TABLE 19 ITCHRO(OBS) morning average score and sBA reduction levels forparticipants (subjects) in the ICONIC clinical study. Serum Bile AcidReduction ItchRO(Obs) Weekly Morning Average Score Normalization of ≥80%from Change from at Week 48 Baseline Baseline to (<8.5 μmol/L) to Week48 Subject ID Baseline Week 48 Week 48 (Y or N) (Y or N) 001021 2.832.71 −0.12 N N 001022 2.71 3.20 0.49 N N 001023 2.29 1.83 −0.45 N N040001 2.43 3.71 1.29 N N 040002^(a)  3.14 040003 4.00 0.14 −3.86 N Y050001 1.86 1.86 0.00 N N 050003 3.29 0.71 −2.57 N N 050004 3.00 1.14−0.86 N N 050005 2.00 0.29 −0.71 N N 050006 3.00 2.00 −0.00 N N 0500073.00 1.71 −0.29 N N 051001 2.67 1.00 −0.67 N N 051002 3.14 2.00 −0.14 NN 052002 3.43 1.71 −0.71 N N 060001 2.43 1.40 −0.03 N N 060002 3.29 0.00−3.29 N N 060003 3.43 0.00 −3.43 N N 060004 2.50 0.00 −2.50 N N 0610012.71 0.00 −2.71 N Y 061002 3.50 0.00 −3.50 Y N 061004 3.29 0.00 −3.29 NN 061005 2.43 1.43 −0.00 N N 061006 2.71 0.00 −2.71 N Y 080001 3.86 1.57−2.29 N N 080003 2.14 0.29 −0.86 N Y 090001 3.67 3.50 −0.17 N N 0900022.57 1.14 −0.43 N N 090003 3.00 2.17 −0.83 N N 090004^(a)  3.57090005^(a)  2.29 ^(a)Subjects do not have data beyond baseline due toearly discontinuations prior to Week 48.

Height Z-score increased by 0.5 (SE, 0.1; p=0.0027) from baseline inparticipants in the ICONIC clinical study, see FIGS. 33-34. Thiscorresponds to a statistically significant acceleration in heightgrowth. Therefore, maralixibat improved growth relative to baseline inpatients suffering ALGS. Moreover, a further increase in growth frombaseline was observed when patients (N=15) were administered 400 μg/kgBID of maralixibat after having been administered a 400 μg/kg QD ofmaralixibat for a period in excess of about 40 weeks. Also, furtherimprovements in sBA, pruritus, and growth were observed followingadministration of the higher daily dose relative to improvementsobserved with administration of 400 μg/kg QD of maralixibat, see FIGS.18 and 23. The increase in growth was also observed as an increase inweight Z-scores, see FIGS. 35-36. As with the height Z-score,administration of maralixibat caused a dose-dependent increase in weightZ-scores, see FIGS. 35-36. Participants administered maralixibat at adose of 400 μg/kg BID of maralixibat after having been administered a400 μg/kg QD of maralixibat for a period in excess of about 40 weeksdemonstrated a greater increase in weight Z-score at 400 μg/kg BID thanat 400 μg/kg QD.

All references cited anywhere within this specification are incorporatedherein by reference in their entirety for all purposes.

While preferred embodiments of the present invention have been shown anddescribed herein, it will be obvious to those skilled in the art thatsuch embodiments are provided by way of example only.

Recitation of ranges of values herein are merely intended to serve as ashorthand method of referring individually to each separate valuefalling within the range and each endpoint, unless otherwise indicatedherein, and each separate value and endpoint is incorporated into thespecification as if it were individually recited herein.

Numerous variations, changes, and substitutions will now occur to thoseskilled in the art without departing from the invention. It should beunderstood that various alternatives to the embodiments of the inventiondescribed herein may be employed in practicing the invention. It isintended that the following claims define the scope of the invention andthat methods and structures within the scope of these claims and theirequivalents be covered thereby.

1. A method for treating or ameliorating cholestatic liver disease in asubject in need thereof, wherein the subject has a bile salt export pump(BSEP) deficiency, the method comprising administering to the subject anApical Sodium-dependent Bile Acid Transport Inhibitor (ASBTI).
 2. Themethod of claim 1, wherein the ASBTI

or a pharmaceutically acceptable salt thereof.
 3. The method of claim 2,wherein the ASBTI is maralixibat, or an alternative pharmaceuticallyacceptable salt thereof.
 4. The method of claim 2, wherein the ASBTI isvolixibat, or a pharmaceutically acceptable salt thereof.
 5. The methodof claim 2, wherein the ASBTI is odevixibat, or a pharmaceuticallyacceptable salt thereof.
 6. The method of claim 2, wherein the ASBTI iselobixibat, or a pharmaceutically acceptable salt thereof.
 7. The methodof claim 2, wherein the ASBTI is GSK2330672, or a pharmaceuticallyacceptable salt thereof.
 8. The method of any one of claims 1-7, whereinthe cholestatic liver disease is progressive familial intrahepaticcholestasis type 2 (PFIC 2), benign recurrent intrahepatic cholestasis(BRIC) or intrahepatic cholestasis of pregnancy (ICP), or biliaryatresia.
 9. The method of any of claims 1-8, wherein the subject hasresidual BSEP function.
 10. The method of claims 1-9, wherein the BSEPdeficiency results in impaired or reduced bile flow or cholestasis. 11.The method of any of claims 1-10, wherein an ABCB11 gene of the subjectcomprises a non-truncating mutation.
 12. The method of claim 11, whereinthe ABCB11 gene comprises one or more of E297G, D482G, an alternativemissense mutation, or a combination thereof.
 13. The method of claim 11,wherein the ABCB11 gene comprises an E297G or a D482G mutation, or both.14. The method of any of claim 11 or 12, wherein the ABCB11 genecomprises a missense mutation and not an E297G or D482G mutation. 15.The method of any of claims 1-13 further comprising determining agenotype of the subject.
 16. The method of claim 15, wherein determiningthe genotype comprises identifying and characterizing a mutation in theABCB11 gene.
 17. The method of claim 16 wherein the ABCB11 gene of thesubject is characterized as comprising only non-truncating mutations.18. The method of claim 1 comprising determining a ratio of serum7α-hydroxy-4-cholesten-2-one (7αC4) concentration to serum bile acid(sBA) concentration (7αC4:sBA) prior to administering the ASBTI at afirst dose level (baseline ratio), and further determining 7αC4:sBAafter the ASBTI administration, wherein the ASBTI administration resultsin a 7αC4:sBA ratio about 2-fold or greater higher than the baseline7αC4:sBA ratio.
 19. The method of claim 18, wherein if the 7αC4:sBAratio begins to decrease or decreases to less than 2-fold or greaterhigher than baseline, a second dose level of the ASBTI is administeredto the subject, wherein the second dose level is higher than the firstdose level.
 20. The method of claim 1, comprising determining a ratio ofserum 7αC4 concentration to sBA concentration (7αC4:sBA) prior toadministering the ASBTI at a first dose level (baseline ratio), andfurther determining 7αC4:sBA after the ASBTI administration, wherein ifthe ASBTI administration fails to result in a 7αC4:sBA ratio about2-fold or greater higher than the baseline 7αC4:sBA ratio, the subjectis administered a second dose level of the ASBTI, wherein the seconddose level is higher than the first dose level.
 21. The method of claim1, further comprising modulating a dose of the ASBTI, the modulatingcomprising determining a ratio of serum 7αC4 concentration to sBAconcentration (7αC4:sBA) prior to administering the ASBTI at a firstdose level (baseline ratio), and further determining 7αC4:sBA after theASBTI administration, wherein if the ASBTI administration fails toresult in a 7αC4:sBA ratio about 2-fold or greater higher than thebaseline 7αC4:sBA ratio the ASBTI is then administered at a second doselevel that does result in a 7αC4:sBA ratio that is about a 2-fold orgreater higher than the baseline ratio.
 22. The method of claim 1,further comprising modulating a dose of the ASBTI, the modulatingcomprising determining a ratio of serum 7αC4 concentration to sBAconcentration (7αC4:sBA) prior to administering the ASBTI at a firstdose level (baseline ratio), and further determining 7αC4:sBA after theASBTI administration, wherein if a treating physician believes the ratiocould be elevated beyond the current level with a higher dose level ofthe ASBTI, then the subject is administered the ASBTI at a second doselevel that results in a 7αC4:sBA ratio that is higher than the baselineratio.
 23. The method of any of claims 19-22, wherein the second dose isat least about twice and less than about five times the first dose. 24.The method of any of claims 1-23, wherein the subject is a pediatricsubject under 18 years of age.
 25. The method of claim 24, wherein theadministration of the ASBTI results in improved growth of the subjectrelative to baseline growth.
 26. The method of claim 25, wherein theimproved growth of the subject is measured as an increase in heightz-score.
 27. The method of any of claims 1-26, wherein the ASBTI isadministered at a daily dose of from about 140 μg/kg to about 1400μg/kg.
 28. The method of claim 27, wherein the ASBTI is administeredonce daily.
 29. The method of claim 27, wherein the ASBTI isadministered twice daily.
 30. The method of any of claims 1-29, whereinthe ASBTI is administered at a daily dose of from about 5 mg/day toabout 100 mg/day.
 31. The method of any of claims 1-30, wherein theASBTI is administered regularly for a period of at least one year. 32.The method of any of claims 1-31, wherein the ASBTI is administeredregularly for a period of at least 4 years.
 33. The method of any ofclaims 1-32, wherein the administration of the ASBTI results in areduction in a symptom or a change in a disease-relevant laboratorymeasure of the cholestatic liver disease that is maintained for at leastone year.
 34. The method of claim 33, wherein the reduction in a symptomor a change in a disease-relevant laboratory measure comprises areduction in sBA concentration, an increase in serum 7αC4 concentration,an increase in a ratio of serum 7αC4 concentration to sBA concentration(7αC4:sBA), a reduction in pruritis, an increase in a quality of lifeinventory score, an increase in a quality of life inventory scorerelated to fatigue, or a combination thereof.
 35. The method of claim34, wherein the reduction in the symptom or a change in adisease-relevant laboratory measure is determined relative to a baselinelevel.
 36. The method of any of claim 33 or 34, wherein the subject is apediatric subject under 18 years of age, and the reduction in a symptomor a change in a disease-relevant laboratory measure comprises anincrease in growth.
 37. The method of any of claims 1-36, wherein theadministration of the ASBTI results in an increase in serum 7αC4concentration.
 38. The method of claim 37, wherein the serum 7αC4concentration is increased from about 1.5-fold to about 40-fold relativeto baseline.
 39. The method of any of claims 1-38, wherein theadministration of the ASBTI results in an increase in a ratio of serum7αC4 concentration to sBA concentration (7αC4:sBA).
 40. The method ofclaim 39, wherein the 7αC4:sBA is increased by from about 2-fold toabout 5,000-fold relative to baseline.
 41. The method of any of claims1-40, wherein the administration of the ASBTI results in an increase infecal bile acids (fBA) of at least 100% relative to baseline.
 42. Themethod of any of claims 1-41, wherein the administration of the ASBTIresults in a decrease in sBA concentration of at least about 70%relative to baseline.
 43. The method of any of claims 1-42, wherein theadministration of the ASBTI results in a reduction in severity ofpruritus.
 44. The method of claim 43, wherein the reduction in severityof pruritis is measured as a reduction of at least 1.0 in anobserver-reported itch reported outcome (ITCHRO(OBS)) score.
 45. Themethod of claim 44, wherein the administration of the ASBTI results inan ITCHRO(OBS) score of ≤1.
 46. The method of any of claims 1-45,wherein the administration of the ASBTI results in an increase in aquality of life inventory score.
 47. The method of claim 46, wherein thequality of life inventory score is a health-related quality of life(HRQoL) score.
 48. The method of claim 46 or 47, wherein the quality oflife inventory score is a Pediatric Quality of Life Inventory (PedsQL)score, and wherein the PedsQL score is increased by at least 10%relative to baseline.
 49. The method of any of claims 1-48, wherein theserum bilirubin concentration is at pre-administration baseline level atabout 4 months after first administration of the ASBTI.
 50. The methodof any of claims 1-49, serum alanine aminotransferase (ALT)concentration is at pre-administration baseline level at about 4 monthsafter first administration of the ASBTI.
 51. The method of any of claims1-50, wherein serum aspartate aminotransferase (AST) concentration, andserum bilirubin concentration are within a normal range at about 4months after first administration of the ASBTI.
 52. The method of any ofclaims 1-51, wherein the administration of the ASBTI results in serumALT concentration decreasing by at least about 10% relative to baseline.53. The method of any of claims 1-52, wherein the subject has biliaryatresia or intrahepatic cholestasis of pregnancy.
 54. A method forpredicting subject response to treatment of a cholestatic liver disease,wherein the treatment comprises administering to the subject in need ofsuch treatment an ASBTI, the method comprising determining a genotype ofthe subject, and predicting subject response to the treatment based uponthe genotype.
 55. The method of claim 54, wherein the ASBTI is

or a pharmaceutically acceptable salt thereof.
 56. The method of claim55, wherein the ASBTI is maralixibat, or an alternative pharmaceuticallyacceptable salt thereof.
 57. The method of claim 55, wherein the ASBTIis volixibat, or a pharmaceutically acceptable salt thereof.
 58. Themethod of claim 55, wherein the ASBTI is odevixibat, or apharmaceutically acceptable salt thereof.
 59. The method of claim 55,wherein the ASBTI is elobixibat, or a pharmaceutically acceptable saltthereof.
 60. The method of claim 55, wherein the ASBTI is GSK2330672, ora pharmaceutically acceptable salt thereof.
 61. The method of any ofclaims 54-60, wherein determining the genotype comprises determining asequence of an ABCB11 gene.
 62. The method of claim 61 furthercomprising identifying and characterizing a mutation of the ABCB11 gene.63. The method of claim 62 further comprising predicting that thesubject will not be responsive to administration of the ASBTI if theABCB11 gene comprises a truncating mutation.
 64. The method of any ofclaim 62 or 63 further comprising predicting that the subject will notbe responsive to administration of the ASBTI if the ABCB11 genecomprises a mutation resulting in total loss of BSEP activity.
 65. Themethod of any of claims 54-64 further comprising predicting that thesubject will be responsive to administration of the ASBTI if the ABCB11gene comprises mutations that result in residual BSEP activity and theABCB11 gene comprises no mutations that result in absence of BSEPactivity.
 66. The method of claim 65, wherein the ABCB11 gene comprisesone or more of an E297G, D482G, an alternative missense mutation, orsome combination thereof.
 67. The method of any of claims 54-Error!Reference source not found., further comprising administering an ASBTIto the subject if the subject is predicted to be responsive to theadministration of the ASBTI.
 68. The method of any of claims 54-67,wherein the subject has biliary atresia or intrahepatic cholestasis ofpregnancy.
 69. A method for treating or ameliorating cholestatic liverdisease in a subject in need thereof, wherein the subject has a BSEPdeficiency, the method comprising: determining a genotype of thesubject; using the genotype of the subject to predict whether thesubject will be or will not be responsive to treatment with an ASBTI;and administering an ASBTI to the subject if the subject is predicted tobe responsive to administration of the ASBTI.
 70. The method of claim69, wherein determining the genotype comprises determining a sequence ofan ABCB11 gene.
 71. The method of claim 70 further comprisingidentifying and characterizing a mutation of the ABCB11 gene.
 72. Themethod of claim 71 further comprising predicting that the subject willnot be responsive to administration of the ASBTI if the ABCB11 genecomprises a truncating mutation.
 73. The method of claim 71 furthercomprising predicting that the subject will not be responsive toadministration of the ASBTI if the ABCB11 gene comprises a mutationresulting in total loss of BSEP activity.
 74. The method of claim 71further comprising predicting that the subject will be responsive toadministration of the ASBTI if the ABCB11 gene comprises mutations thatresult in residual BSEP activity and the ABCB11 gene comprises nomutations that result in absence of BSEP activity.
 75. The method of anyof claim 71 or 74, wherein the ABCB11 gene comprises one or more of anE297G, D482G, an alternative missense mutation, or some combinationthereof.
 76. The method of claim 69 further comprising determining aratio of serum 7αC4 concentration to serum bile acid (sBA) concentration(7αC4:sBA) prior to administering the ASBTI at a first dose (baselineratio), and further determining the 7αC4:sBA after the ASBTIadministration.
 77. The method of claim 76, further comprisingadministering a second dose of the ASBTI, wherein the second dose isgreater than the first dose, if after the administration of the firstdose of the ASBTI the 7αC4:sBA is not maintained about >2-fold higherthan the baseline ratio.
 78. The method of claim 76, further comprisingadministering a second dose of the ASBTI, wherein the second dose isgreater than the first dose, if the 7αC4:sBA initially increases by atleast >2-fold higher than the baseline ratio and then begins to decreaseback to the baseline ratio.
 79. The method of any of claim 77 or 78,wherein the second dose is at least about twice and less than about fivetimes the second dose.
 80. The method of any of claims 69-79, whereinthe subject is a pediatric subject under 18 years of age.
 81. The methodof claim 80, wherein the administration of the ASBTI results in improvedgrowth of the subject.
 82. The method of claim 81, wherein improvedgrowth of the subject is measured as an increase in height z-score. 83.The method of any of claims 69-82, wherein the ASBTI is administered ata daily dose of from about 140 μg/kg to about 1400 μg/kg.
 84. The methodof any of claims 69-83, wherein the ASBTI is administered once daily.85. The method of any of claims 69-84, wherein the ASBTI is administeredtwice daily.
 86. The method of any of claims 69-85, wherein the ASBTI isadministered at a dose of from about 5 mg/day to about 100 mg/day. 87.The method of any of claims 69-86, wherein the ASBTI is administeredregularly for a period of at least one year.
 88. The method of any ofclaims 69-87, wherein the ASBTI is administered regularly for a periodof at least 4 years.
 89. The method of any of claims 69-88 wherein theadministration of the ASBTI results in a reduction in a symptom or achange in a disease-relevant laboratory measure of the cholestatic liverdisease that is maintained for at least one year.
 90. The method ofclaim 89, wherein the reduction in a symptom or a change in adisease-relevant laboratory measure comprises a reduction in sBAconcentration, an increase in serum 7αC4 concentration, an increase in aratio of serum 7αC4 concentration to sBA concentration (7αC4:sBA), areduction in pruritis, an increase in a quality of life inventory score,an increase in a quality of life inventory score related to fatigue, ora combination thereof.
 91. The method of claim 90, wherein the reductionin the symptom or a change in a disease-relevant laboratory measure isdetermined relative to a baseline level.
 92. The method of any of claim89 or 90, wherein the subject is a pediatric subject under 18 years ofage and the reduction in a symptom or a change in a disease-relevantlaboratory measure comprises an increase in growth.
 93. The method ofany of claims 69-92, wherein the administration of the ASBTI results inan increase in serum 7αC4 concentration.
 94. The method of claim 93,wherein the serum 7αC4 concentration is increased from about 1.5-fold toabout 40-fold relative to baseline.
 95. The method of claim 93, whereinthe serum 7αC4 concentration is increased by at least 100% relative tobaseline.
 96. The method of any of claims 69-95, wherein theadministration of the ASBTI results in an increase in a ratio of serum7αC4 concentration to sBA concentration (7αC4:sBA).
 97. The method ofclaim 96, wherein 7αC4:sBA is increased by from about 2-fold to about5,000-fold relative to baseline.
 98. The method of any of claims 69-97,wherein the administration of the ASBTI results in an increase in fBA ofat least 100% relative to baseline.
 99. The method of claim any ofclaims 69-98, wherein the administration of the ASBTI results in adecrease in sBA concentration of at least about 70% relative tobaseline.
 100. The method of any of claims 69-99, wherein theadministration of the ASBTI results in a reduction in severity ofpruritus.
 101. The method of claim 100, wherein the reduction inseverity of pruritis is measured as a reduction of at least 1.0 in anobserver-reported itch reported outcome (ITCHRO(OBS)) score relative tobaseline.
 102. The method of claim 100 or 101, wherein theadministration of the ASBTI results in an ITCHRO(OBS) score of ≤1. 103.The method of any of claims 69-102, wherein the administration of theASBTI results in an increase in a quality of life inventory score. 104.The method of claim 103, wherein the quality of life inventory score isa health-related quality of life (HRQoL) score.
 105. The method of anyof claim 103 or 104, wherein the quality of life inventory score is aPediatric Quality of Life Inventory (PedsQL) score.
 106. The method ofclaim 105, wherein the PedsQL score is increased by at least 10%relative to baseline.
 107. The method of any of claims 69-106, whereinserum bilirubin concentration is at pre-administration baseline level atabout 4 months after first administration of the ASBTI.
 108. The methodof any of claims 69-107, wherein serum ALT concentration is atpre-administration baseline level at about 4 months after firstadministration of the ASBTI.
 109. The method of any of claims 69-108,wherein serum ALT concentration, serum AST concentration, and serumbilirubin concentration being are within a normal range at about 4months after first administration of the ASBTI.
 110. The method of anyof claims 69-109, wherein the administration of the ASBTI results inserum ALT concentration decreasing by at least about 10% relative tobaseline.
 111. The method of any of claims 69-110, wherein the subjecthas biliary atresia or intrahepatic cholestasis of pregnancy.
 112. Themethod of any of claims 69-111, wherein the subject has PFIC 2.